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 B
Explanation
A. Ears: Evaluation of the ears is primarily concerned with hearing and balance, which involve cranial nerves such as VIII (Vestibulocochlear), not IX, X, and XII.
B. Mouth and throat: Cranial nerves IX (Glossopharyngeal), X (Vagus), and XII (Hypoglossal) are assessed through the examination of the mouth and throat. CN IX and X are evaluated by checking the gag reflex and the ability to swallow, while CN XII is assessed by examining tongue movements.
C. Head and face: The assessment of the head and face generally involves cranial nerves V (Trigeminal) and VII (Facial), which control facial sensation and movement, rather than IX, X, and XII.
D. Mental status examination: While mental status is crucial for overall health assessment, it does not specifically target cranial nerves IX, X, and XII.
Correct Answer is C
Explanation
A. Ectropion: This condition involves the eyelid turning outward, not drooping.
B. Presbyopia: This is age-related loss of near vision, not related to eyelid position.
C. Ptosis: Ptosis refers to drooping of the upper eyelid, which is the correct term for the described finding.
D. Entropion: This condition involves the eyelid turning inward, not drooping.
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