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

Percuss diaphragmatic excursion.

Palpate tactile fremitus on the posterior chest.

Observe the appearance of the thorax.

Auscultate the client's breath sounds.

Answer and Explanation

The Correct Answer is C

A. Percuss diaphragmatic excursion: Percussion of diaphragmatic excursion helps evaluate the movement of the diaphragm during respiration but does not directly confirm the physical appearance or structural change associated with a barrel chest.

B. Palpate tactile fremitus on the posterior chest: Tactile fremitus assesses vibration transmission through lung tissue and can indicate consolidation or air trapping, but it is not useful for visually confirming a barrel-shaped chest.

C. Observe the appearance of the thorax: A barrel chest is a visual and structural change where the chest appears rounded and expanded due to increased anterior-posterior (AP) diameter of the chest , often seen in chronic respiratory conditions like COPD. Observing the shape and configuration of the thorax is the most direct and accurate method to confirm this physical finding.

D. Auscultate the client's breath sounds: Auscultation reveals the presence or absence of breath sounds and abnormal respiratory patterns but does not provide confirmation of chest shape. It is valuable in assessing lung function, not thoracic structure.

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Correct Answer is C

Explanation

A. Ecchymosis: Ecchymosis refers to larger areas of bruising or discoloration due to bleeding under the skin, typically caused by trauma. It appears as purple or bluish patches but does not present as tiny pinpoint spots.

B. Hematoma: A hematoma is a localized collection of blood under the skin or tissue that results in swelling and discoloration. It is typically raised and larger than petechiae, often caused by blunt force trauma.

C. Petechiae: Petechiae are small, pinpoint, round red or purple spots caused by minor bleeding under the skin. They are flat, do not blanch with pressure, and are often associated with pressure or trauma. In the context of intimate partner violence, petechiae can be a sign of strangulation or other abuse-related injuries.

D. Vesicle: A vesicle is a small, fluid-filled blister on the skin, commonly associated with infections like herpes or chickenpox. They appear as a raised lesion containing clear fluid. It is not red or pinpoint in appearance and would not match the described findings in this scenario.

A. Observe the client's eye movements through the cardinal fields of vision. B. Observe the client's pupillary response to a penlight. C. Observe the client's optic disc through an ophthalmoscope. D. Assess the client's ability to read a Snellen chart from a distance of 20 feet.

Correct Answer is D

Explanation

A. Observe the client's eye movements through the cardinal fields of vision: This test evaluates extraocular muscle function and cranial nerves III, IV, and VI. It helps detect muscle weakness or nerve damage but does not measure visual acuity or diagnose legal blindness.

B. Observe the client's pupillary response to a penlight: This assesses the integrity of the optic and oculomotor nerves and reflexes, such as pupil constriction. While useful in neurological assessments, it does not determine the level of visual acuity needed to confirm legal blindness.

C. Observe the client's optic disc through an ophthalmoscope: Direct visualization of the optic disc can reveal issues like glaucoma or optic atrophy. However, it does not quantify vision loss or determine functional blindness as defined by acuity measurements.

D. Assess the client's ability to read a Snellen chart from a distance of 20 feet: This is the standard method for evaluating visual acuity. Legal blindness is defined in the U.S. as visual acuity of 20/200 or worse in the better eye with corrective lenses, making this test the most appropriate for supporting the client’s statement.

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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 C

Explanation

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Correct Answer is D

Explanation

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