A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?

Inspection of the shape and configuration of the chest during normal breathing

Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10

Percussion of the posterior chest to initiate vibration of the lung structures

Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety nine’’

Answer and Explanation

The Correct Answer is B

A) Inspection of the shape and configuration of the chest during normal breathing:
While inspecting the shape and configuration of the chest can provide important information about potential deformities or abnormalities (such as a barrel chest or scoliosis), it does not directly assess the symmetry of chest expansion. Inspection primarily focuses on the external appearance rather than the physiological movement of the chest wall during respiration. Symmetry of chest expansion requires more than visual observation; it involves assessing the movement of the chest during inhalation and exhalation.

B) Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10:
This technique is the most effective for confirming symmetric expansion of the chest. The nurse places their hands on the patient's back, with the thumbs positioned at the level of T9 or T10, and asks the patient to take a deep breath. As the patient inhales, the nurse assesses the expansion of both sides of the chest by observing whether the thumbs move apart symmetrically. This test directly evaluates the expansion of the lungs and chest wall during respiration and is the most accurate way to assess symmetry.

C) Percussion of the posterior chest to initiate vibration of the lung structures:
Percussion is a technique used to assess the underlying lung tissue and the presence of conditions like pneumonia, fluid accumulation, or air trapping. It does not directly assess the symmetry of chest expansion. While percussion may provide valuable diagnostic information about the lungs, it does not help in determining how evenly the chest is expanding during normal breathing.

D) Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety-nine":
This technique refers to vocal fremitus, where the nurse places their hands on the client's chest while the client repeats "ninety-nine." It helps assess the transmission of sound vibrations through the chest wall, which can be used to detect areas of consolidation or fluid in the lungs. However, it does not directly evaluate the symmetry of chest expansion. The vibration felt on both sides of the chest may be different in cases of lung disease, but this test does not assess the movement of the chest during breathing.

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Correct Answer is D

Explanation

A) Obtain a throat culture for possible streptococcal (strep) infection:
A throat culture would be indicated if the client presents with symptoms of a strep throat infection, such as a sore throat, fever, or difficulty swallowing. However, the description of involuted, granular tonsils with deep crypts is typically a normal finding, particularly in adults. This appearance is not suggestive of a bacterial infection like strep throat, which usually presents with signs of acute inflammation, exudates, or tenderness. Therefore, a throat culture is not necessary based on these findings alone.

B) Continue with the assessment, looking for any other abnormal findings:
While continuing the assessment is important in any physical exam, the appearance of granular, involuted tonsils with deep crypts is generally considered a normal anatomical variation, particularly in adults. There is no indication of an abnormality that would require further investigation unless other concerning symptoms are present. If no other abnormal findings are identified, no additional action is needed at this point.

C) Refer the client to their primary provider:
Referral to a primary provider would be appropriate if there were signs of infection, significant symptoms, or concerns about the tonsils, such as severe swelling, pain, or visible pus. However, the description of the tonsils as involuted and granular, with deep crypts, does not suggest a need for referral. This is a normal variation, and no referral is necessary unless other abnormal findings or symptoms are present.

D) No response is needed; this appearance is normal for the tonsils:
This is the correct response. Tonsils can naturally become more granular and involuted (shrunken or indented) as a person ages. The deep crypts are also a normal feature of tonsils and do not necessarily indicate pathology. These findings are typically seen in adults and do not require intervention unless accompanied by signs of infection or other abnormalities. Therefore, no further action is necessary for this normal anatomical appearance.

A. Use the Snellen chart positioned 20 feet away from the client B. Determine the client’s ability to read newsprint at a distance of 12 to 14 inches C. Perform the confrontation test D. Ask the client to read the print on a handheld jaeger card

Correct Answer is A

Explanation

A) Use the Snellen chart positioned 20 feet away from the client:
This is the correct method for assessing visual acuity in adults. The Snellen chart is the standard tool used to measure visual acuity at a distance. The client is positioned 20 feet away from the chart, and they are asked to read the smallest line of letters they can clearly identify. The result is typically documented as a fraction (e.g., 20/20), where the numerator represents the distance from the chart, and the denominator represents the distance at which a person with normal vision can read the same line. This test assesses distance vision and is essential for checking overall visual sharpness.

B) Determine the client’s ability to read newsprint at a distance of 12 to 14 inches:
This is not used to assess visual acuity; it assesses near vision and can be part of the overall vision examination, but it is not the standard method for testing visual acuity. Typically, the near vision assessment is done with tools like a Jaeger chart or by asking the client to read newsprint at a standard reading distance (12 to 14 inches), but this is not the primary test for visual acuity. The Snellen chart is specifically for distance vision.

C) Perform the confrontation test:
The confrontation test is used to assess the visual fields, not visual acuity. It is a quick screening to determine if the client has any peripheral vision loss, where the nurse and the client compare their visual fields by covering one eye at a time and identifying moving fingers in the periphery. While important, this test does not assess the sharpness or clarity of central vision, which is the focus of a visual acuity test.

D) Ask the client to read the print on a handheld Jaeger card:
The Jaeger card is used to assess near vision, not visual acuity. It is used for clients who may have difficulty reading small print at a normal reading distance and helps assess presbyopia (difficulty focusing on near objects with age). However, this test is for near vision and is not the primary test for visual acuity, which typically focuses on distance vision.

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A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. nurse should recognize that which of the following is the correct response to these findings?

Correct Answer is D

Explanation

A nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Correct Answer is A

Explanation

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