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 B

Explanation

A. Explain the tests to the wife so she can interpret them for her husband: While involving family members can be helpful in some situations, it is essential for the client to actively participate in sensory assessments. Having the wife interpret the tests may not give an accurate representation of the client’s sensory capabilities.

B. Assess the client's ability to follow directions before proceeding with the exam: Accurate sensory testing relies on the client's ability to understand and follow instructions, as well as to accurately report sensations. It is important to first evaluate whether the client can understand and follow instructions, as cognitive or memory issues may affect their ability to engage in the sensory exam. This step ensures that the assessment results are valid and reflective of the client’s true sensory function.

C. Defer this part of the exam because the results are likely to be invalid: While cognitive decline can impact the reliability of the exam, it is essential to assess the client's ability to participate and follow instructions before determining whether the sensory exam can be conducted properly. Deferring the exam without evaluation of comprehension is inappropriate.

D. Perform the tests because the client's mental status does not affect sensory status: While mental status may not directly affect the sensory pathways, the ability to follow directions and focus on the exam does influence the accuracy of the assessment. Proceeding without assessing the client's ability to participate could result in inaccurate findings.

A. "Count backwards by 7, starting with 100." B. "Has anyone come to visit you today?" C. "In what year were you born?" D. "What does, "The early bird catches the worm," mean?"

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.

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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

While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

Correct Answer is B

Explanation

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

Correct Answer is D

Explanation

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