A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?

Anteroposterior-to-transverse diameter ratio of 1:1

Unequal chest expansion

Atrophied neck and trapezius muscles

Increased tactile fremitus

Answer and Explanation

The Correct Answer is A

A. Anteroposterior-to-transverse diameter ratio of 1:1: In COPD, chronic air trapping leads to hyperinflation of the lungs, causing a "barrel chest" appearance where the anteroposterior (AP) diameter approaches or equals the transverse diameter (1:1 ratio). This is a hallmark physical finding in advanced stages of the disease.

B. Unequal chest expansion: COPD causes diffuse rather than localized lung pathology, leading to generally reduced but symmetrical chest expansion. Unequal expansion is more characteristic of conditions like pneumothorax, pleural effusion, or unilateral lung consolidation.

C. Atrophied neck and trapezius muscles: Patients with COPD often develop hypertrophy of the neck and accessory muscles due to chronic respiratory effort, not atrophy. These muscles become more prominent as they assist with breathing, especially during exacerbations.

D. Increased tactile fremitus: Fremitus is the vibration felt on the chest wall when a patient speaks. In COPD, hyperinflation and air trapping decrease lung density, leading to reduced tactile fremitus. Increased fremitus is typically found in conditions with lung consolidation, such as pneumonia.

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Correct Answer is A

Explanation

A. Pericardial sac: The pericardial sac, also known as the pericardium, is a double-walled sac that surrounds and protects the heart. It consists of an outer fibrous layer and an inner serous layer, which produces pericardial fluid to reduce friction between the heart and surrounding structures during heartbeats. This structure provides support and helps maintain the position of the heart within the thorax.

B. Endocardial sac: The endocardium is the innermost layer of the heart wall that lines the heart chambers and covers the heart valves. It does not refer to a protective sac surrounding the heart.

C. Pleural sac: The pleural sac consists of two layers (visceral and parietal pleura) that encase the lungs and provide a lubricated surface for lung expansion and contraction during respiration. It is not related to the heart.

D. Myocardial sac: The myocardium refers to the muscular middle layer of the heart wall responsible for contraction and pumping blood. It is not a sac and does not surround or protect the heart.

A. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure. B. Have the mother attempt to bottle feed the infant. C. Assure the mother that these signs are normal symptoms of a cold. D. Recognize that these are serious signs, and contact the physician.

Correct Answer is D

Explanation

A. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure: While congenital heart disease can present with respiratory distress, the presence of nasal flaring and retractions in an infant with a prolonged upper respiratory infection strongly suggests respiratory distress due to a pulmonary cause, such as bronchiolitis or pneumonia. A cardiac assessment may be necessary, but immediate intervention for respiratory distress is the priority.

B. Have the mother attempt to bottle feed the infant: Infants in respiratory distress often struggle with feeding due to increased work of breathing. Attempting to bottle feed could further compromise oxygenation and increase fatigue, worsening the child's condition.

C. Assure the mother that these signs are normal symptoms of a cold: Nasal flaring and intercostal retractions are signs of increased respiratory effort, indicating significant respiratory distress rather than a mild viral upper respiratory infection. These findings warrant prompt medical evaluation.

D. Recognize that these are serious signs, and contact the physician: Nasal flaring, sternal retractions, and intercostal retractions indicate significant respiratory distress, which can rapidly progress to respiratory failure in infants. Immediate assessment and intervention by a healthcare provider are necessary to ensure appropriate treatment and monitoring.

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A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The sac that surrounds and protects the heart is called?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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