The nurse is performing the technique shown. What is the nurse assessing?
Tactile fremitus
Chest expansion
Breath sounds
Tissue consolidation
The Correct Answer is B
A. Tactile fremitus: This involves palpating vibrations on the chest wall as the patient speaks, not assessing chest expansion.
B. Chest expansion: This technique assesses the symmetrical movement of the chest during inhalation and exhalation, which is the correct assessment for this context.
C. Breath sounds: Breath sounds are assessed through auscultation rather than palpation.
D. Tissue consolidation: This involves detecting areas of increased density in lung tissue, often assessed through percussion or auscultation, not through the technique shown for chest expansion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Fever: While fever might be a symptom of infection, it is not specific to inner ear infections.
B. Headache: This can be a symptom associated with inner ear infections, but vertigo is a more specific concern.
C. Vertigo: Inner ear infections often cause vertigo (dizziness or spinning sensations), so interventions for managing vertigo are crucial.
D. Rhinorrhea: This symptom is more commonly associated with upper respiratory infections rather than inner ear infections.
Correct Answer is D
Explanation
A. Planning: Planning involves setting goals and interventions based on data collected, but data collection itself is not part of this phase.
B. Diagnosis: Diagnosis involves analyzing collected data to identify health issues, but data collection is a separate process that occurs before this phase.
C. Evaluation: Evaluation assesses the effectiveness of interventions and progress towards goals, but data collection is performed earlier in the process.
D. Assessment: Data collection is a fundamental part of the assessment phase in the nursing process, where information is gathered to identify patient needs and conditions.
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