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

Shoulder flexion, which involves extending the arms up to 180 degrees beside the ears, represents the full normal range of motion for the glenohumeral joint. This movement assesses the combined function of the deltoid, supraspinatus, and biceps brachii muscles, indicating optimal mobility of the shoulder joint. A normal range is 0 to 180 degrees of flexion.

Choice B rationale

Holding arms up at 90 degrees while arms are pushed downward tests muscle strength against resistance, specifically of the deltoid. While an important component of shoulder assessment, it evaluates strength rather than the full range of motion. This maneuver assesses the integrity of the rotator cuff and surrounding musculature.

Choice C rationale

Alternating both index fingers to touch the tip of the nose accurately is a test of cerebellar function and coordination, assessing proprioception and fine motor control. This technique is not used to evaluate the range of motion of the shoulder joint. It helps identify neurological deficits, such as ataxia.

Choice D rationale

Extending arms straight out and holding without drifting, commonly known as the Romberg test (when standing) or pronator drift, assesses balance and subtle motor weakness, especially indicative of upper motor neuron lesions. This technique does not specifically measure the range of motion of the shoulder.

A. Query the client about related symptoms. B. Inspect the urethral meatus for discharge. C. Observe the scrotum for swelling. D. Palpate the inguinal area for a bulge.

Correct Answer is A

Explanation

Choice A rationale

Querying the client about related symptoms, such as weak stream, hesitancy, incomplete emptying, or straining, directly assesses the impact of prostatic enlargement on bladder function. These symptoms are classic indicators of benign prostatic hyperplasia (BPH), which commonly causes nocturia and difficulty initiating urination due to urethral compression.

Choice B rationale

Inspecting the urethral meatus for discharge is primarily indicated for assessing sexually transmitted infections or urethritis. While urethral issues can cause voiding problems, discharge is not a typical symptom of BPH and therefore does not directly provide further data related to nocturia and difficulty starting a stream.

Choice C rationale

Observing the scrotum for swelling is relevant for detecting conditions like epididymitis, orchitis, or hydrocele. While these conditions can cause discomfort, they are not typically associated with the classic urinary hesitancy and nocturia pattern reported, making this assessment less directly relevant to the client's chief complaints.

Choice D rationale

Palpating the inguinal area for a bulge assesses for hernias, which can cause pain or discomfort in the groin but typically do not directly cause urinary symptoms such as nocturia or difficulty initiating a urine stream. Therefore, this assessment would not yield relevant data for the reported urinary complaints.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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