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. Soft, barely heard on auscultation in a quiet room: This description refers to a murmur of a lower grade, Grade I, not a grade IV murmur. Grade I murmurs are very faint and may not be heard in all positions. A grade IV murmur is typically loud enough to be heard clearly and would likely be associated with a palpable thrill, which is not consistent with a soft murmur.

B. Moderately loud, machine-like rumble, not associated with a thrill: This description does not align with a grade IV systolic murmur, which is generally louder and more associated with a palpable thrill. A machine-like rumble could be indicative of a Grade III murmur or a different type of murmur, possibly related to other valvular conditions, but it would not match the characteristics of a grade IV systolic murmur.

C. Loud, at the apex, associated with a palpable thrill: A grade IV systolic murmur is loud and often associated with a palpable thrill, which can be felt at the apex of the heart, particularly in mitral valve regurgitation. This finding is consistent with the characteristics of a grade IV murmur and accurately reflects its clinical presentation.

D. Very loud, with no stethoscope, thrill easily palpable, heave visible: This description refers to a grade V or grade VI murmur, which is very loud and can be heard without a stethoscope. It also includes the visible heave, which is not typical for a grade IV murmur. Therefore, this is too extreme for the situation described.

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

Correct Answer is C

Explanation

A. Observe the scrotum for swelling: Scrotal swelling might indicate issues such as a hydrocele, varicocele, or hernia, but it is not directly linked to urinary difficulties like nocturia or trouble initiating urination. It’s not the most targeted assessment in this context.

B. Inspect the urethral meatus for discharge: Discharge can suggest infection, such as urethritis or sexually transmitted infections, but it’s not a common finding in cases of nocturia and hesitancy typically associated with prostate issues.

C. Question the client about related symptoms: Asking about related symptoms such as weak stream, dribbling, incomplete emptying, or urgency helps the nurse assess for conditions like benign prostatic hyperplasia (BPH). This focused history provides critical insight into urinary function and guides further evaluation or referral.

D. Palpate the inguinal area for a bulge: This checks for inguinal hernias, which can cause groin discomfort but are not typically linked with urinary hesitancy or nocturia. It's a useful exam, but not the most relevant first step based on the symptoms presented.

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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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Explanation

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