A nurse is performing an assessment of an adult client and observes unequal chest expansion. The nurse should recognize that unequal chest expansion I occur for which reason?

When the client is obese

When part of the lung is obstructed or collapsed

When accessory muscles are used to facilitate respiratory effort

When bulging of the intercostal spaces is present

Answer and Explanation

The Correct Answer is B

A) When the client is obese:
While obesity can affect the overall ease of breathing due to increased fat tissue around the chest and abdomen, it is not a direct cause of unequal chest expansion. Obesity can limit the depth of breath and potentially make it harder for the chest to expand fully, but it would not typically cause asymmetry in the movement of the chest on one side. Unequal chest expansion is more likely to occur due to underlying respiratory or structural issues.

B) When part of the lung is obstructed or collapsed:
This is the most accurate reason for unequal chest expansion. If part of the lung is obstructed (such as with a mucous plug or foreign body) or collapsed (as in the case of pneumothorax or atelectasis), it prevents that area of the lung from fully expanding during inspiration. As a result, the affected side of the chest will expand less than the opposite side. This can be a critical finding and warrants immediate further investigation to determine the cause and ensure appropriate treatment.

C) When accessory muscles are used to facilitate respiratory effort:
While the use of accessory muscles (e.g., the sternocleidomastoid, scalene, and intercostal muscles) often occurs during labored breathing, it does not specifically result in unequal chest expansion. Accessory muscle use typically occurs in conditions like severe asthma, chronic obstructive pulmonary disease (COPD), or respiratory distress, where there is an increased effort to breathe, but it doesn't cause asymmetry in the chest's movement. Unequal chest expansion is usually related to a localized problem in the lung or pleura, not the general use of muscles.

D) When bulging of the intercostal spaces is present:
Bulging of the intercostal spaces may suggest increased pressure in the pleural space, such as in the case of a pleural effusion or severe respiratory distress. However, while bulging intercostal spaces can be a sign of a respiratory condition, it is not typically associated with unequal chest expansion. Instead, bulging could indicate that the lung or chest wall is under stress or that there is fluid accumulation, which would lead to other physical findings like decreased breath sounds or dullness to percussion, but it does not directly cause unequal expansion. Unequal expansion is more likely to occur when part of the lung is obstructed or collapsed

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. A blend of fibrous, glandular, and adipose tissues B. Primarily milk ducts which function a milk reservoirs C. Primarily muscle with small amounts of fibrous tissue D. Glandular tissue to attach the breast to the chest wall

Correct Answer is A

Explanation

A) A blend of fibrous, glandular, and adipose tissues: The internal structure of the breast is composed of a mixture of fibrous, glandular, and adipose tissues. The glandular tissue is responsible for producing milk, the fibrous tissue provides structural support, and the adipose tissue stores fat. This combination of tissues gives the breast its shape and functional capabilities, making it a complex and dynamic organ.

B) Primarily milk ducts which function as milk reservoirs: While the breast does contain milk ducts that transport milk from the glandular tissue to the nipple, it is not primarily composed of these ducts. The milk ducts are an important component, but they do not make up the majority of the breast's internal structure. The blend of different tissues is what defines the breast’s anatomy.

C) Primarily muscle with small amounts of fibrous tissue: The breast itself does not contain significant muscle tissue. The primary muscles related to the breast are the pectoral muscles, which lie beneath the breast tissue but are not part of the internal breast structure. The internal breast primarily consists of fibrous, glandular, and adipose tissues, not muscle.

D) Glandular tissue to attach the breast to the chest wall: The glandular tissue is crucial for milk production, but it does not function to attach the breast to the chest wall. The attachment of the breast to the chest wall is facilitated by the Cooper's ligaments, which are fibrous bands that help maintain structural integrity. Glandular tissue primarily serves the function of milk production.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is performing an assessment of an adult client and observes unequal chest expansion. The nurse should recognize that unequal chest expansion I occur for which reason?

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 is teaching a client about internal structures of the breast. The should understand that the internal breast consists what structures?

Correct Answer is A

Explanation

A nurse is preparing to auscultate for heart sounds on a client. Which technique should be used by the nurse?

A nurse is examining a male client within normal weight range who is questioning about the cause of his enlarged breasts. Which course of action best describes how the nurse should address the client's bilateral gynecomastia?

A nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?

A nurse is discussing the blood flow pattern of the heart. The nurse should recognize which of the following as the accurate blood flow pattern of the heart?

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?

A nurse is performing an examination of a client's anterior thorax. The nurse should recall that the trachea bifurcates anteriorly at which location?

A nurse is assessing the anterior chest of a client. The nurse recognizes that which of the following should be included in the assessment? (Select all that apply.)

A nurse is performing a lung assessment on a client. The nurse should understand which information about lung structures?