A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

Palpate the chest symmetrically

Ask the client to cough

Use the bell of the stethoscope

instruct the client to breathe deeply

Answer and Explanation

The Correct Answer is A

A) Palpate the chest symmetrically:
Palpating the chest symmetrically is crucial when assessing tactile fremitus, as it allows the nurse to compare the intensity of vibrations felt on both sides of the chest. Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary system when a person speaks or breathes. Symmetrical palpation ensures that the nurse can detect any differences in fremitus, which may indicate abnormalities such as lung consolidation (e.g., pneumonia), pleural effusion, or pneumothorax. Uneven fremitus can suggest a pathological condition, and symmetrical palpation helps identify these variations.

B) Ask the client to cough:
Asking the client to cough is not directly related to the assessment of tactile fremitus. Coughing may be used in other aspects of the respiratory assessment (e.g., to clear secretions or to assess for a productive cough), but it is not necessary for palpating fremitus. Tactile fremitus is assessed while the client is speaking (e.g., repeating the phrase "ninety-nine") or breathing, not coughing.

C) Use the bell of the stethoscope:
The bell of the stethoscope is used for auscultating low-pitched sounds, such as heart murmurs or some lung sounds (e.g., certain adventitious sounds like crackles or wheezes). However, it is not used for palpating tactile fremitus, which is a physical exam technique that involves using the hands to feel for vibrations. Fremitus is a tactile (not auscultatory) finding, so the stethoscope, whether bell or diaphragm, is not relevant in this assessment.

D) Instruct the client to breathe deeply:
While it is important for the client to breathe deeply during a lung exam, deep breathing is not directly required for assessing tactile fremitus. Tactile fremitus is typically assessed while the client is speaking. When the client repeats a phrase like "ninety-nine," vibrations are transmitted through the chest wall, and the nurse can assess the intensity of the vibrations. Deep breathing would be more relevant for assessing breath sounds or the general respiratory effort.

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Correct Answer is D

Explanation

A) Obtain a throat culture for possible streptococcal (strep) infection:
A throat culture for streptococcal infection is generally warranted when there are signs and symptoms of a bacterial infection, such as a sore throat, fever, exudate on the tonsils, or swollen lymph nodes. The description provided—involuted, granular tonsils with deep crypts—is a normal, age-related finding and not indicative of an infection. Therefore, obtaining a throat culture is unnecessary unless additional clinical signs of infection are present.

B) Continue with the assessment, looking for any other abnormal findings:
While it is always important to complete a thorough assessment and look for other abnormal findings, the specific characteristics described (involuted, granular tonsils with deep crypts) are normal, particularly in adults. This is a common finding and does not require further investigation unless accompanied by other symptoms such as pain, swelling, or visible pus, which would warrant a closer look.

C) Refer the client to their primary provider:
Referral to a primary provider is generally recommended if there are significant concerns about the tonsils, such as persistent swelling, pain, or signs of infection. However, the description provided does not suggest a pathological issue; these characteristics are typically considered normal in adults. Referral would only be necessary if additional concerning symptoms were present, such as fever, difficulty swallowing, or changes in voice.

D) No response is needed; this appearance is normal for the tonsils:
This is the correct response. Involuted (shrunken), granular tonsils with deep crypts are a normal, age-related finding, especially in adults. Over time, the tonsils tend to shrink and develop more pronounced crypts (pockets). This is part of the natural aging process and is not usually a sign of pathology. These tonsil changes are often seen in individuals who have had repeated infections or as part of the natural aging process.

A. High cholesterol B. Diabetes C. Age D. Weight E. Smoking

Correct Answer is ["A","B","D","E"]

Explanation

A) High cholesterol: Elevated cholesterol levels, particularly low-density lipoprotein (LDL) cholesterol, are a significant risk factor for cardiovascular disease. High cholesterol can lead to the buildup of plaques in the arteries, which increases the risk of heart attacks and strokes. Managing cholesterol through diet, exercise, and medication can reduce cardiovascular risk.

B) Diabetes: Diabetes, especially poorly controlled blood sugar levels, significantly increases the risk of cardiovascular disease. High blood glucose can damage blood vessels and nerves, leading to complications such as coronary artery disease and stroke. Effective management of diabetes through lifestyle changes and medication can help mitigate these risks.

C) Age: While age is a risk factor for cardiovascular disease, it is a non-modifiable factor. As people age, the risk of developing cardiovascular issues naturally increases due to changes in the cardiovascular system. Since age cannot be altered, it is not included in the list of modifiable risk factors.

D) Weight: Excess body weight, particularly obesity, is associated with an increased risk of cardiovascular disease. Obesity contributes to conditions like hypertension, diabetes, and dyslipidemia, all of which elevate cardiovascular risk. Weight management through diet, exercise, and healthy lifestyle choices is crucial for reducing this risk.

E) Smoking: Smoking is a major modifiable risk factor for cardiovascular disease. It damages the blood vessels, increases blood pressure, and reduces oxygen supply to the heart, contributing to the development of atherosclerosis and other cardiovascular conditions. Quitting smoking is one of the most effective ways to lower cardiovascular risk

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A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

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. The nurse should recognize that which of the following is the correct response to these findings?

Correct Answer is D

Explanation

A nurse s teaching a group of clients about modifiable risk factors for cardiovascular disease. Which of the following should the nurse include in the teaching? (Select All that Apply).

Correct Answer is ["A","B","D","E"]

Explanation

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A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

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