The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?

Presence of breath sounds

Diaphragmatic excursion

Symmetric chest expansion

Shape and configuration of the chest wall

Answer and Explanation

The Correct Answer is D

. Presence of breath sounds: While assessing the anterior chest, the nurse should listen for breath sounds over various areas of the lungs. However, this is related to auscultation, not inspection.

B. Diaphragmatic excursion: Diaphragmatic excursion involves assessing the movement of the diaphragm during breathing. This is typically done by percussing the level where dullness changes to resonance during inhalation and exhalation. It is more related to percussion, not inspection.

C. Symmetric chest expansion: Symmetric chest expansion refers to the equal expansion of both sides of the chest during inhalation. The nurse can observe and palpate the chest to assess if it expands symmetrically on both sides. This is a crucial aspect of the inspection of the anterior chest.

D. Shape and configuration of the chest wall: The shape and configuration of the chest wall, including abnormalities or deformities, should be assessed during inspection. This includes observing for any asymmetry, deformities, masses, or scars on the anterior chest.

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Correct Answer is C

Explanation

A. Friction rub:

A friction rub is a grating or rubbing sound or sensation heard or felt during auscultation or palpation. It occurs when inflamed pleural or pericardial surfaces rub against each other during breathing or heartbeats, respectively.

B. Tactile fremitus:

Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks. It is assessed by placing hands on the patient's back while the patient speaks certain words. Increased tactile fremitus can occur in conditions with lung consolidation, such as pneumonia.

C. Crepitus:

Crepitus is a crackling or grating sensation felt under the skin or heard when the ends of a broken bone rub against each other. It can also occur when air leaks into subcutaneous tissue, leading to a crackling sensation upon palpation.

D. Adventitious sounds:

Adventitious sounds refer to abnormal lung sounds heard during auscultation. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. Adventitious sounds can indicate various respiratory conditions, such as pneumonia, bronchitis, or asthma.

A. Age B. Smoking C. Hypertension D. Diabetes E. High cholesterol

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.

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The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is palpating a client's anterior chest wall and notices a course, crackling sensation over the skin surface. Which of the following should the nurse suspect from her findings?

Correct Answer is C

Explanation

The nurse is teaching a group of clients about modifiable risk factors for cardiovascular disease. Which of the following should the nurse include in the teaching? (Select all that apply)

Correct Answer is ["B","C","D","E"]

Explanation

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