What should the nurse feel when placing their hands on the posterior lateral chest during a deep breath?
Pain during chest expansion
Symmetrical rise and fall of the rib cage
Asymmetrical rise and fall of the rib cage
No movement of the rib cage
The Correct Answer is B
Choice A reason: Pain during chest expansion, often called pleuritic chest pain, is an abnormal finding. It may indicate pleurisy, where the pleural layers are inflamed and rub against each other. A healthy client should be able to take a deep breath comfortably without any stabbing or localized pain sensations during the maneuver.
Choice B reason: During the assessment of thoracic expansion, the nurse places their thumbs at the level of T9 or T10. As the client inhales deeply, the nurse's hands should move outward symmetrically. This indicates that both lungs are inflating equally and that the musculoskeletal structures of the chest wall are functioning uniformly on both sides.
Choice C reason: Asymmetrical rise and fall of the rib cage is a significant clinical abnormality. It suggests that one lung is not expanding fully, which can be seen in conditions such as massive atelectasis, pneumothorax, or pleural effusion on the affected side. This finding necessitates immediate further diagnostic investigation to determine the underlying cause of the restriction.
Choice D reason: A total lack of movement of the rib cage during a deep breath would indicate a profound respiratory failure, severe restrictive disease, or a neurological impairment of the diaphragm and intercostal muscles. In a living, breathing client, there should always be a palpable excursion of the thoracic cage during the inspiratory phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A reason: A blood pressure of 168/91 mmHg combined with a headache may indicate a hypertensive urgency or emergency. This requires immediate follow-up to prevent potential target organ damage, such as a cerebrovascular accident or acute renal failure, and to initiate appropriate pharmacological interventions to lower the pressure safely.
Choice B reason: While 96/63 mmHg might be normal for some, the subjective report of "feeling faint" suggests symptomatic hypotension or orthostatic intolerance. This requires follow-up to assess for dehydration, cardiac output issues, or medication side effects to prevent falls and ensure adequate cerebral and systemic perfusion.
Choice C reason: Capillary refill should ideally be less than 2 seconds. A delay of 4 seconds indicates poor peripheral perfusion or compromised arterial flow to the extremity. This finding necessitates further neurovascular assessment to rule out conditions like peripheral artery disease or acute limb ischemia.
Choice D reason: A heart rate of 112 (tachycardia) paired with an irregular rhythm is a pathological finding that could indicate atrial fibrillation or another dysrhythmia. This requires an electrocardiogram (ECG) to identify the specific rhythm and assess the risk of thromboembolism or hemodynamic instability.
Choice E reason: The combination of jugular vein distention and coarse crackles strongly suggests biventricular heart failure with pulmonary edema. This is a critical state of fluid volume overload that requires urgent nursing action, including high-Fowler’s positioning, oxygen therapy, and the administration of diuretics to improve gas exchange.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Aging leads to structural changes in the chest wall and spine, such as kyphosis, which increases the anteroposterior diameter. This "barrel chest" appearance occurs as the thoracic cage becomes less flexible and the lungs lose their ability to fully collapse during the expiration phase.
Choice B reason: Vital capacity actually decreases with age due to the loss of lung elasticity and weakened respiratory muscles. The lungs become less compliant, and the residual volume increases, meaning the maximum amount of air an individual can expel after a maximum inhalation is significantly reduced.
Choice C reason: The aging process involves the degradation of elastin fibers within the lung parenchyma, leading to decreased elastic recoil. This loss of "snap-back" ability results in smaller airway collapse during expiration, leading to air trapping and a decrease in the efficiency of gas exchange within the alveoli.
Choice D reason: With advancing age, the costal cartilages that connect the ribs to the sternum undergo calcification, making the rib cage more rigid. This increased stiffness raises the work of breathing as the respiratory muscles must work harder to expand the less compliant thoracic cavity during inspiration.
Choice E reason: Hyperresonance is an expected percussion finding in older adults because of the increased air trapping and anatomical changes associated with decreased lung elasticity. The relative increase in air-to-tissue ratio in the lungs produces a lower-pitched, hollower sound when the chest wall is percussed.
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