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 D

Explanation

A. "Count backwards by 7, starting with 100.": This question assesses concentration, attention span, and mathematical ability but does not evaluate abstract thinking. It is typically used in cognitive or mental status exams to assess focus and processing speed.

B. "Has anyone come to visit you today?": This is a straightforward question assessing recent memory or orientation but has no abstract component. It provides little insight into higher-order thinking or interpretation skills.

C. "In what year were you born?": This question evaluates remote memory, not abstract reasoning. It is factual and concrete, requiring only recollection, not interpretation or deeper thought.

D. "What does, 'The early bird catches the worm,' mean?": This is a proverb that requires interpretation beyond its literal meaning. Asking for its meaning helps assess abstract thinking by evaluating the client’s ability to understand figurative language and draw broader conclusions.

A. Right breath sounds louder than left. B. Slight crackling throughout lung fields. C. Faint whistling over both lung bases. D. Blowing, hollow sounds above sternum.

Correct Answer is D

Explanation

A. Right breath sounds louder than left: While there might be slight variations, breath sounds should generally be equal in intensity on both sides of the chest. Breath sounds should be relatively equal bilaterally. Asymmetry in sound intensity can indicate consolidation, obstruction, or a pneumothorax.

B. Slight crackling throughout lung fields: Crackles (rales) are abnormal sounds typically associated with fluid in the alveoli, as seen in conditions like heart failure, pneumonia, or pulmonary fibrosis. They are not a normal finding in healthy lung tissue.

C. Faint whistling over both lung bases: Whistling or high-pitched sounds suggest wheezing, often caused by narrowed airways due to asthma, bronchitis, or other obstructive airway diseases. This is considered an abnormal finding.

D. Blowing, hollow sounds above sternum: These describe bronchial breath sounds, which are normally heard over the trachea and manubrium (above the sternum). They have a blowing, hollow quality and are considered a normal finding in that location.

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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 D

Explanation

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