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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Encourage the client to keep checking the mole with a magnifying mirror: While regular self-monitoring of skin lesions is helpful for early detection, it is not an appropriate response when significant changes in a mole have already occurred. This approach delays necessary evaluation and possible diagnosis of skin cancer.

B. Advise the client to see his healthcare provider (HCP) for immediate evaluation: A mole that has darkened and increased in size could indicate malignant melanoma, a serious form of skin cancer. These changes align with the "ABCDE" criteria often used to identify suspicious moles: Asymmetry, Border irregularity, Color change, Diameter, Evolving. Prompt evaluation by a healthcare provider is crucial for early diagnosis and potential life-saving treatment.

C. Offer to teach a family member how to monitor the skin around the mole: Although involving family members in health monitoring can be supportive, it does not replace the need for immediate professional assessment when concerning changes in a mole are reported.

D. Ask the client if he often spends time outside in the sun without a shirt: Exploring sun exposure is relevant in skin cancer risk assessment, but it is not the priority action in this situation. The immediate concern is the suspicious change in the mole, which requires urgent medical attention.

A. "It doesn't take much activity before I'm out of breath." B. "I sleep on three pillows at night." C. "I cough a lot at night and it keeps me up half the night." D. "I have multiple attacks of wheezing almost daily."

Correct Answer is B

Explanation

A. "It doesn't take much activity before I'm out of breath.": This statement describes exertional dyspnea, which is shortness of breath with physical activity. It is often seen in heart or lung conditions but does not point to orthopnea, which occurs when lying flat.

B. "I sleep on three pillows at night.": Using multiple pillows to sleep is a compensatory behavior for orthopnea. Orthopnea is defined as difficulty breathing while lying flat, often related to heart failure and pulmonary congestion, and is relieved by elevating the head.

C. "I cough a lot at night and it keeps me up half the night.": Nocturnal coughing may indicate asthma, GERD, or postnasal drip. While it disrupts sleep, it does not clearly signify orthopnea, which is specifically related to positional shortness of breath.

D. "I have multiple attacks of wheezing almost daily.": Frequent wheezing attacks are more consistent with conditions like asthma or COPD. This symptom does not suggest orthopnea, which involves positional breathing difficulty, not episodic wheezing.

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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 B

Explanation

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Correct Answer is B

Explanation

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