A nurse is assessing the anterior chest of a client. The nurse recognizes that which of the following should be included in the assessment? (Select all that apply.)

Kyphosis

Gastrointestinal sounds

Heart sounds

Breath sounds

Symmetric expansion

Answer and Explanation

Correct Answer : C,D,E

A) Kyphosis: While kyphosis is an important physical finding that could impact a client's respiratory and musculoskeletal health, it is typically assessed during the general physical examination and postural assessment rather than as part of the anterior chest assessment. Therefore, kyphosis is not directly part of the anterior chest examination, though it could be a factor influencing respiratory mechanics.

B) Gastrointestinal sounds: Gastrointestinal sounds are assessed during the abdominal examination, not the chest examination. The anterior chest exam focuses on respiratory and cardiac assessments, which do not involve auscultating bowel sounds. Hence, gastrointestinal sounds are not part of the chest examination.

C) Heart sounds: Auscultation of heart sounds is a crucial part of assessing the anterior chest, as it helps the nurse evaluate cardiac function. The nurse listens to heart sounds at specific areas on the chest (e.g., aortic, pulmonic, tricuspid, and mitral areas) to identify any abnormalities such as murmurs, arrhythmias, or other issues.

D) Breath sounds: Breath sounds are an essential component of the chest assessment. By auscultating the lungs, the nurse can identify normal or abnormal breath sounds, such as wheezes, crackles, or decreased breath sounds, which may indicate respiratory issues like pneumonia, asthma, or emphysema.

E) Symmetric expansion: Symmetric expansion refers to the even movement of both sides of the chest during inhalation and exhalation. Assessing symmetric chest expansion helps the nurse identify any respiratory abnormalities, such as atelectasis, pneumonia, or other lung pathologies that may cause uneven chest expansion, signaling a potential underlying issue.

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Correct Answer is B

Explanation

A) Demonstrate that both arteries will be palpated simultaneously to compare amplitude: This is not recommended. Palpating both carotid arteries simultaneously can cause a decrease in blood flow to the brain, potentially leading to dizziness or syncope. It is important to palpate one carotid artery at a time to avoid reducing blood flow to the brain, especially in clients with cardiovascular disease or those at risk of stroke.

B) Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates: This is the correct approach. Instructing the client to hold their breath helps minimize any interference from respiratory sounds while auscultating the carotid arteries for bruits. This technique ensures that breath sounds do not mask any abnormal vascular sounds, such as bruits, which could indicate a blockage or narrowing of the carotid arteries.

C) Discuss that a light will be directed at the neck to observe for pulsations of the artery: Observing pulsations with light is not an appropriate technique for assessing the carotid arteries. Pulsations may be visible in some cases, but palpation and auscultation are the more reliable methods for evaluating the carotid arteries for abnormalities such as bruits or reduced pulse amplitude.

D) Show the client the diaphragm of the stethoscope that will be placed on the neck: While it is appropriate to explain the process to the client, the action of showing the stethoscope is unnecessary at this stage. The focus should be on instructing the client to hold their breath for proper auscultation to listen for any abnormal vascular sounds.

A. These sounds are normally auscultated over the trachea B. These are bronchial breath sounds and normal in that location C. These are bronchovesicular breath sounds and normal in that location D. These are vesicular breath sounds and normal in that location

Correct Answer is D

Explanation

A) These sounds are normally auscultated over the trachea:
This is incorrect. The tracheal breath sounds are harsh, loud, and high-pitched, typically heard over the trachea and larynx. These characteristics differ from the soft, low-pitched sounds described in the question, which are more consistent with vesicular breath sounds.

B) These are bronchial breath sounds and normal in that location:
This is incorrect. Bronchial breath sounds are typically heard over the trachea and larynx, not the lower lobes of the lungs. Bronchial sounds are loud, high-pitched, and have a longer expiration phase compared to inspiration, unlike the low-pitched, soft sounds with longer inspiration that are heard in the lower lobes.

C) These are bronchovesicular breath sounds and normal in that location:
This is incorrect. Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds, with inspiration and expiration of about equal duration. They are typically heard over the major bronchi, near the sternum and between the scapulae, rather than over the posterior lower lobes. The description in the question suggests vesicular breath sounds, which have a longer inspiration phase.

D) These are vesicular breath sounds and normal in that location:
This is the correct answer. Vesicular breath sounds are soft, low-pitched, and typically heard over the peripheral lung fields, including the posterior lower lobes. These sounds have a longer inspiration phase than expiration and are considered normal in this location. The description in the question fits the characteristics of vesicular breath sounds perfectly.

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A nurse is assessing the anterior chest of a client. The nurse recognizes that which of the following should be included in the assessment? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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