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
A. XII: Cranial nerve XII (hypoglossal) controls tongue movements, but is not typically assessed by the technique described.
B. V: Cranial nerve V (trigeminal) is assessed for facial sensation and mastication, not the technique in question.
C. VII: Cranial nerve VII (facial) is responsible for facial expressions and is assessed by asking the client to perform various facial movements.
D. XI: Cranial nerve XI (accessory) is involved in shoulder and neck movements, not facial expressions.
Correct Answer is D
Explanation
A. It is easiest for the client to learn: While the ease of learning is important, the primary goal is effective detection of masses.
B. It takes the least amount of time: The time taken is less critical than the effectiveness of the technique in detecting abnormalities.
C. It causes the least amount of pain: Minimizing pain is not the main reason for choosing a particular technique; effectiveness in detecting masses is more critical.
D. It is the best technique to detect masses: The recommended pattern, often the vertical strip or circular pattern, is chosen because it is the most effective way to systematically cover the breast tissue and increase the likelihood of detecting abnormalities or masses.
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