A nurse is caring for a 40-year-old female client in an outpatient clinic.

Which of the following primary skin lesions contain fluid?

Choice A rationale

Percussing diaphragmatic excursion assesses the movement of the diaphragm during respiration, reflecting lung expansion and function. While relevant to respiratory assessment, it does not directly confirm the anatomical characteristic of a barrel chest, which is a structural alteration of the thoracic cage.

Choice B rationale

Auscultating breath sounds evaluates airflow through the respiratory passages, identifying adventitious sounds like wheezes or crackles. Although individuals with a barrel chest may have altered breath sounds due to lung hyperinflation, auscultation does not directly confirm the physical presence of the barrel chest deformity itself.

Choice C rationale

Observing the appearance of the thorax allows for direct visual assessment of the anteroposterior (AP) diameter in relation to the transverse diameter. A barrel chest is characterized by an increased AP diameter, often approaching a 1: ratio, which is a key visual diagnostic criterion for this chronic respiratory condition.

Choice D rationale

Palpating tactile fremitus assesses the transmission of vibrations through the lung tissue during vocalization. While providing information about lung consolidation or obstruction, it is not a primary method for confirming the characteristic structural deformity of an increased anteroposterior diameter associated with a barrel chest.

Choice A rationale: Observing respirations for rate, rhythm, and depth is crucial in pneumonia management as respiratory compromise may develop rapidly. Changes in respiratory pattern such as tachypnea, irregular rhythm, or shallow breaths can indicate worsening lung function, hypoxia, or impending respiratory failure, requiring immediate intervention.

Choice B rationale: Inspecting skin and mucous membranes helps assess for signs of hypoxia or poor perfusion, such as cyanosis or pallor. These findings can indicate inadequate oxygen delivery due to impaired lung function in pneumonia. Monitoring skin integrity is also important for infection control and early detection of complications.

Choice C rationale: Measuring the apical pulse for 60 seconds is important in cardiac assessments, especially if arrhythmias or murmurs are suspected. However, in pneumonia without cardiac symptoms or abnormal heart sounds, continuous assessment of apical pulse is not prioritized in a focused respiratory assessment.

Choice D rationale: Auscultating the chest is essential to evaluate breath sounds for signs of consolidation, crackles, or diminished air entry, which directly reflect pneumonia severity and progression. Regular auscultation helps guide treatment decisions and detect complications like pleural effusion or pneumothorax.

Choice E rationale: Having the client demonstrate incentive spirometer use ensures proper technique, promoting lung expansion and preventing atelectasis. Correct use reduces pulmonary complications and supports recovery, making it an important part of nursing assessment and education in pneumonia care.

Choice F rationale: Determining heart rhythm is important in cardiac assessments, but in the absence of arrhythmia symptoms or abnormal ECG findings, it is not a primary focus in pneumonia care. Monitoring vital signs regularly is sufficient unless clinical indications suggest otherwise.