To confirm the presence of a barrel chest documented in the client's medical record, which action should the nurse take?

Percuss diaphragmatic excursion.

Auscultate the client's breath sounds.

Observe the appearance of the thorax.

Palpate tactile fremitus on the posterior chest.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Percussing diaphragmatic excursion assesses the movement of the diaphragm during respiration, reflecting lung expansion and function. While relevant to respiratory assessment, it does not directly confirm the anatomical characteristic of a barrel chest, which is a structural alteration of the thoracic cage.

Choice B rationale

Auscultating breath sounds evaluates airflow through the respiratory passages, identifying adventitious sounds like wheezes or crackles. Although individuals with a barrel chest may have altered breath sounds due to lung hyperinflation, auscultation does not directly confirm the physical presence of the barrel chest deformity itself.

Choice C rationale

Observing the appearance of the thorax allows for direct visual assessment of the anteroposterior (AP) diameter in relation to the transverse diameter. A barrel chest is characterized by an increased AP diameter, often approaching a 1: ratio, which is a key visual diagnostic criterion for this chronic respiratory condition.

Choice D rationale

Palpating tactile fremitus assesses the transmission of vibrations through the lung tissue during vocalization. While providing information about lung consolidation or obstruction, it is not a primary method for confirming the characteristic structural deformity of an increased anteroposterior diameter associated with a barrel chest.

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Correct Answer is A

Explanation

Choice A rationale

Legal blindness is clinically defined as a corrected visual acuity of 20/200 or less in the better eye, or a visual field of 20 degrees or less. The Snellen chart directly assesses visual acuity by requiring the client to identify letters of decreasing size at a standardized distance of 20 feet. This method directly measures the client's ability to discern detail at a distance, which is the primary parameter for legal blindness.

Choice B rationale

Observing the optic disc with an ophthalmoscope primarily assesses the health of the optic nerve and retinal vasculature, which can indicate conditions like glaucoma or diabetic retinopathy. While these conditions can lead to visual impairment, ophthalmoscopy itself does not directly quantify visual acuity or field deficits. It is a structural assessment, not a functional visual acuity measurement.

Choice C rationale

Observing cardinal fields of vision assesses extraocular muscle function and cranial nerve integrity. This technique helps identify nystagmus, strabismus, or gaze palsies. While these conditions can affect visual function and coordination, they do not directly measure the degree of central visual acuity required to determine legal blindness. It assesses eye movement, not visual clarity.

Choice D rationale

Observing pupillary response to a penlight assesses the function of the oculomotor nerve (cranial nerve III) and the integrity of the afferent and efferent pathways of the pupillary light reflex. Abnormal responses can indicate neurological issues or eye pathology. However, pupillary response does not directly measure visual acuity or visual field, which are the diagnostic criteria for legal blindness.

A. Borborygmi sounds. B. Hyperactive bowel sounds. C. Normal bowel sounds. D. Hypoactive bowel sounds.

Correct Answer is C

Explanation

Choice A rationale

Borborygmi refers to loud, prolonged gurgles, or rumbling sounds, often audible without a stethoscope, indicating increased bowel motility. While the sounds described are gurgles, their frequency (every 5-10 seconds) and distribution across all quadrants suggest a normal physiological process rather than the excessive, prolonged, and often hyperactive sounds characteristic of borborygmi.

Choice B rationale

Hyperactive bowel sounds are characterized by frequent, loud, and high-pitched sounds, occurring more than 30 times per minute. The described gurgles occurring every 5 to 10 seconds (6 to 12 sounds per minute) do not meet the criteria for hyperactive bowel sounds, which would indicate significantly increased intestinal motility often associated with conditions like diarrhea or gastroenteritis.

Choice C rationale

Normal bowel sounds are typically soft gurgles or clicks, occurring irregularly at a rate of 5 to 30 times per minute. The nurse's finding of gurgles lasting about 3 seconds and occurring every 5 to 10 seconds in all quadrants falls within this normal range, indicating appropriate intestinal peristalsis and function throughout the digestive tract.

Choice D rationale

Hypoactive bowel sounds are infrequent and quiet, occurring less than 5 times per minute. The described frequency of gurgles, occurring every 5 to 10 seconds (6 to 12 sounds per minute), is much more frequent than what would be classified as hypoactive, which often suggests decreased bowel motility due to conditions such as ileus or constipation.

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To confirm the presence of a barrel chest documented in the client's medical record, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client states, "I am legally blind.”. Which assessment technique should the nurse use to obtain data to support the client's statement?

Correct Answer is A

Explanation

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Correct Answer is C

Explanation

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