The nurse is assessing the symmetry of the client's chest. The nurse recognizes that a client's symmetric expansion of the chest is best confirmed by:
Percussion of the posterior chest
Inspection of the shape and configuration of the chest wall
Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety nine"
Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10
The Correct Answer is D
A. Percussion of the posterior chest: Percussion helps assess the underlying structures of the chest but does not directly confirm symmetric chest expansion.
B. Inspection of the shape and configuration of the chest wall: Inspection is a crucial part of assessing chest symmetry. Any deformities, asymmetry, or abnormalities in the shape and configuration of the chest wall can be visually identified.
C. Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety-nine": This technique, known as tactile fremitus, involves feeling for vibrations or tremors while the client repeats a phrase. While it can provide information about underlying lung conditions, it's not primarily used to confirm symmetric chest expansion.
D. Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10: This technique, known as chest expansion measurement, is used to assess symmetric chest expansion. Placing hands in this manner allows the nurse to feel for bilateral chest expansion during inspiration, ensuring that both sides of the chest expand symmetrically.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Age: While age itself is not modifiable, it is included in the list because aging increases the risk of developing cardiovascular disease. However, individuals cannot change their age, so it is not a modifiable risk factor.
B. Smoking: Smoking is a significant risk factor for cardiovascular disease. It damages the heart and blood vessels and can lead to atherosclerosis (narrowing and hardening of the arteries), which can result in heart attacks and strokes.
C. Hypertension: High blood pressure is a leading cause of cardiovascular disease. It can damage the arteries over time, making them more susceptible to atherosclerosis.
D. Diabetes: Diabetes, especially if poorly controlled, increases the risk of cardiovascular disease. High blood sugar levels can damage the blood vessels and the heart.
E. High cholesterol: Elevated levels of cholesterol, especially low-density lipoprotein (LDL) cholesterol, can lead to the buildup of plaque in the arteries, increasing the risk of atherosclerosis and cardiovascular events.
Correct Answer is B
Explanation
A. Have the client breathe quickly:
This choice is incorrect because having the client breathe quickly is not a technique for assessing tactile fremitus. Tactile fremitus is assessed by feeling vibrations on the chest wall while the patient speaks, not during normal breathing.
B. Palpate the chest symmetrically:
This choice is correct. To assess tactile fremitus, the nurse places the palms or ulnar aspects of both hands firmly against the patient's chest while the patient speaks a phrase. The nurse should palpate the chest symmetrically to detect vibrations equally on both sides, which can help identify abnormalities in the lungs.
C. Ask the client to cough:
This choice is incorrect. Asking the client to cough is not a technique for assessing tactile fremitus. Tactile fremitus is evaluated by feeling vibrations while the patient speaks, not while coughing.
D. Use the bell of the stethoscope:
This choice is incorrect. Tactile fremitus is assessed by palpation, not auscultation with a stethoscope. Using the bell of the stethoscope is a technique for listening to low-pitched sounds, not for assessing tactile fremitus.
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