A nurse is precepting a new nurse on respiratory assessments. Which statement by the new nurse indicates an understanding of what should be felt during the assessment when placing hands on the posterior lateral chest during deep breathing?
Symmetrical rise and fall of the rib cage
Pain during chest expansion
Crepitus sensation across the rib cage
No movement of the rib cage
The Correct Answer is A
Choice A reason: Assessment of thoracic excursion or chest expansion is a vital part of the respiratory exam. The nurse should feel the hands move apart symmetrically as the client inhales deeply. This indicates that the musculoskeletal structures, the pleural membranes, and the underlying lung parenchyma are expanding uniformly on both the left and right sides of the thorax.
Choice B reason: Pain during expansion, or pleuritic pain, is a pathological finding that suggests inflammation of the parietal pleura. A student or new nurse should recognize that a normal assessment is painless. Feeling pain during this maneuver indicates a need for further investigation into conditions such as pleurisy, pulmonary embolism, or rib fractures.
Choice C reason: Crepitus is a tactile "crunching" or "popping" sensation caused by air trapped in the subcutaneous tissues, often referred to as subcutaneous emphysema. While this is an important finding to document if present, it is an abnormal condition resulting from trauma or air leaks and is not a feature of a normal respiratory assessment.
Choice D reason: A total lack of movement of the rib cage during deep inspiration would indicate severe respiratory compromise, such as neuromuscular paralysis or advanced restrictive lung disease. The goal of the assessment is to quantify the degree and symmetry of movement; therefore, "no movement" would be a critical clinical finding rather than an expected result.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: A pleural friction rub is a grating sound produced by the inflammation of the visceral and parietal pleurae. This finding is typically associated with pleuritis or pneumonia rather than the pulmonary venous congestion and transudative fluid shifts that characterize uncomplicated left-sided congestive heart failure.
Choice B reason: Dyspnea on exertion in heart failure patients leads to increased work of breathing. As pulmonary compliance decreases due to interstitial edema, the client must recruit secondary muscles, such as the sternocleidomastoids and scalenes, to facilitate adequate thoracic expansion and maintain sufficient alveolar ventilation and gas exchange.
Choice C reason: In left-sided heart failure, high hydrostatic pressure in the pulmonary capillaries forces fluid into the alveoli. This edema fluid mixes with air and surfactant, producing a characteristic white or pinkish frothy sputum. This is a classic hallmark of acute pulmonary congestion and worsening cardiac function.
Choice D reason: An S3 gallop, or ventricular gallop, occurs early in diastole during the rapid ventricular filling phase. It is a key clinical indicator of ventricular overfilling or decreased myocardial compliance, which are central pathophysiological features of fluid volume overload in patients with left-sided heart failure.
Choice E reason: An increased anteroposterior chest diameter, or barrel chest, is a structural adaptation resulting from chronic air trapping and alveolar hyperinflation. This finding is characteristic of chronic obstructive pulmonary disease, particularly emphysema, rather than the acute or chronic pulmonary edema seen in left-sided heart failure.
Correct Answer is B
Explanation
Choice A reason: Asymmetrical chest expansion is typically associated with structural or pleural pathologies, such as a pneumothorax, large pleural effusion, or fractured ribs. Kussmaul's respiration is a systemic metabolic response rather than a localized mechanical issue, and it generally involves profound, symmetrical thoracic excursions as the body attempts to compensate for severe acidosis.
Choice B reason: Kussmaul's breathing is characterized by a markedly increased respiratory rate, often reaching 30 breaths per minute or higher, combined with extreme depth. This hyperpnea is a compensatory mechanism for metabolic acidosis, specifically diabetic ketoacidosis, where the lungs attempt to "blow off" excess carbon dioxide to increase the systemic pH levels.
Choice C reason: A respiratory rate of 10 breaths per minute indicates bradypnea, which is the opposite of the hyperventilation seen in Kussmaul's breathing. Bradypnea may be caused by central nervous system depression, opioid overdose, or end-stage respiratory failure, whereas Kussmaul's represents an active, vigorous effort by the respiratory center to expel acid.
Choice D reason: Shallow chest expansion is characteristic of hypoventilation or restrictive lung disease, not Kussmaul's. Kussmaul's respirations are famously "air hungry" and deep, involving maximal recruitment of respiratory muscles. Shallow breathing would lead to carbon dioxide retention, which would exacerbate the very metabolic acidosis that Kussmaul's breathing is designed to rectify.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.