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
Explanation
A. Glandular tissue, which supports the breast by attaching to the chest wall: Glandular tissue is indeed a part of the breast structure, but it is not responsible for supporting the breast by attaching to the chest wall. It's the Cooper's ligaments, which are fibrous connective tissue, that provide structural support.
B. Fibrous, glandular, and adipose tissues: This statement is correct. The breast is composed of glandular tissue (responsible for milk production), fibrous tissue (including Cooper's ligaments for support), and adipose tissue (fat).
C. Primarily muscle with very little fibrous tissue: The breast contains very little muscle tissue. The main supportive structure is fibrous tissue, not muscle.
D. Primarily milk ducts, known as lactiferous ducts: Milk ducts are part of the glandular tissue and are responsible for carrying milk. However, the breast is not primarily made up of milk ducts; it consists of a combination of glandular, fibrous, and adipose tissues.
Correct Answer is D
Explanation
A. Perform the confrontation test:
The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.
B. Ask the patient to read the print on a handheld Jaeger card:
Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.
C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:
This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.
D. Use the Snellen chart positioned 20 feet away from the patient:
The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.
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