In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Looking at the client from the side, observe the size and shape of the chest wall.

Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.

Place the palm of the hand on the chest wall to feel vibrations while the client speaks.

Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly.

Answer and Explanation

The Correct Answer is C

A) Looking at the client from the side, observe the size and shape of the chest wall:
This action is more related to inspecting the physical appearance and symmetry of the chest wall but does not assess tactile fremitus.

B) Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation:
This action may be more relevant for assessing subcutaneous emphysema (crepitus) but is not the correct method for assessing tactile fremitus.

C) Place the palm of the hand on the chest wall to feel vibrations while the client speaks:
This is the correct action to assess tactile fremitus. By placing the palm of the hand on various areas of the chest wall while the client repeats a phrase such as "ninety-nine," the nurse can feel for vibrations. Increased tactile fremitus can indicate consolidation, as seen in pneumonia.

D) Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly:
This action involves auscultation, which is important for assessing breath sounds but does not assess tactile fremitus directly.

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Correct Answer is A

Explanation

Answer: A. "Have you been sleeping well?"

Rationale:

A) "Have you been sleeping well?": Sleep deprivation can lead to symptoms such as an expressionless facial affect, slurred speech, and red conjunctivae. Assessing for sleep patterns is a priority to rule out this common and reversible cause of the client's symptoms. Sleep deprivation can also exacerbate other underlying conditions.

B) "Have you been depressed lately?": While depression could explain the expressionless affect, it does not typically cause slurred speech or red conjunctivae. Depression can be assessed later if other immediate causes are ruled out.

C) "Have you had anything to eat in the last 24 hours?": Poor nutritional intake could contribute to fatigue or weakness but is less likely to cause all the observed symptoms (expressionless affect, slurred speech, and red conjunctivae). This question is important but not the first priority.

D) "Have you ever had problems with your blood sugar?": Blood sugar imbalances, particularly hypoglycemia or hyperglycemia, can cause neurological changes. However, the symptoms described are less specific to blood sugar issues and more indicative of sleep or neurological concerns, making this question less immediately relevant.

A. Hypogastric region. B. Epigastric region. C. Umbilical region. D. Hypochondriac region.

Correct Answer is B

Explanation

A) Hypogastric region:
The hypogastric region, also known as the suprapubic region, is located below the umbilical region and above the pubic area. Pain in the hypogastric region would be lower in the abdomen than described.

B) Epigastric region:
The epigastric region is located in the upper central part of the abdomen, just below the xiphoid process. Pain localized in the middle section of the abdomen below the xiphoid process is described as occurring in the epigastric region.

C) Umbilical region:
The umbilical region is located around the navel (belly button). Pain in this area would be centered around the umbilicus and not higher up near the xiphoid process.

D) Hypochondriac region:
The hypochondriac regions are located on either side of the epigastric region and below the ribcage. Pain in the hypochondriac region would be more lateral and not centrally located below the xiphoid process.

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In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..."

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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