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

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Correct Answer is B

Explanation

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.

A. Whisper random numbers letters, then have the client repeat them B. Shield the lips so that the sound is muffled C. Stand approximately 4 feet away from the client D. Have the client place a finger in the ear canal to occlude outside noise

Correct Answer is A

Explanation

A) Whisper random numbers and letters, then have the client repeat them:
This is correct. The voice test is a simple way to assess a client's hearing. The nurse should stand about 2 feet away from the client and whisper random numbers or letters. The client should repeat what they hear. This test checks the ability to hear and distinguish sounds, particularly for high-frequency tones. It's an effective screening method for detecting hearing loss.

B) Shield the lips so that the sound is muffled:
This is incorrect. The nurse should not shield their lips during the voice test because it could interfere with the client's ability to hear and potentially read the nurse's lips, which can help with understanding. The client should be allowed to observe lip movements to aid in comprehension of the sounds being spoken.

C) Stand approximately 4 feet away from the client:
This is incorrect. The recommended distance for performing the voice test is typically around 2 feet, not 4 feet. Standing too far away can make it more difficult for the client to hear the whispered numbers or letters and could affect the accuracy of the test. The nurse should stand close enough (about 2 feet) to ensure that the sound is audible to the client but not too close as to distort the test.

D) Have the client place a finger in the ear canal to occlude outside noise:
This is incorrect. While the client should be instructed to avoid distractions or loud environments during the test, placing a finger in the ear canal is not necessary. The test assesses the client's ability to hear sound, and occluding the ear could affect the results. The client should simply be in a quiet environment.

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

Correct Answer is B

Explanation

A nurse is performing a voice test to assess a client's hearing. Which of these actions should the nurse perform?

Correct Answer is A

Explanation

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