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 A

Explanation

A) Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation, typically occurring at the end of inspiration. These crackles are often heard in the bases of the lungs, particularly when the client is in a supine position, and are not associated with any pathological condition. Atelectatic crackles are a normal finding, especially in a sleeping or newly awakened client, as they result from the temporary collapse of small airways that quickly re-expand. Since they disappear after a few breaths and are not indicative of disease, they should be documented as atelectatic crackles without a pathological cause.

B) Fine crackles that may be a sign of impending pneumonia:
Fine crackles are high-pitched, popping sounds that are often heard during inspiration, especially at the lung bases. They are commonly associated with conditions like pneumonia, heart failure, or pulmonary fibrosis. However, in this case, the crackles heard stopped after a few breaths, which is characteristic of atelectatic crackles rather than fine crackles associated with pathological conditions. Fine crackles that last and occur consistently may suggest pathology, but in this scenario, the transient nature of the sounds points to atelectatic crackles, not pneumonia.

C) Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung fields, characterized by a soft, low-pitched sound during inspiration, with a shorter expiration. These sounds are different from crackles, which are brief, popping sounds. Vesicular breath sounds do not refer to abnormal or adventitious sounds, such as the crackles heard in this client. Therefore, the nurse should not document the breath sounds as vesicular.

D) Fine wheezes:
Wheezes are continuous musical sounds produced by the narrowing of the airways, typically heard during exhalation. They are usually caused by conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. The crackling sounds described in the question are not wheezes, as they are short, popping sounds rather than musical, continuous sounds. The transient nature of the sounds makes them more consistent with atelectatic crackles, not wheezes.

A. Crackles B. Stridor C. Dyspnea D. Friction rub

Correct Answer is D

Explanation

A) Crackles: Crackles are abnormal lung sounds often associated with conditions such as pneumonia, heart failure, or pulmonary edema. They result from fluid in the airways or alveoli. However, crackles are not typically the primary finding in pleuritis, which involves inflammation of the pleura.

B) Stridor: Stridor is a high-pitched wheezing sound caused by an obstruction or narrowing of the upper airway, often seen in conditions such as croup or anaphylaxis. It is not characteristic of pleuritis, which involves inflammation of the pleura and not airway obstruction.

C) Dyspnea: Dyspnea, or difficulty breathing, is a common symptom in many respiratory conditions, including pleuritis. While pleuritis can lead to discomfort during breathing, dyspnea itself is not a sound that would be auscultated. It’s a subjective feeling that would be noted during the client’s history or verbal report, rather than an auscultatory finding.

D) Friction rub: A pleural friction rub is the most expected finding when auscultating a client with pleuritis. This sound occurs when the inflamed pleural layers rub against each other during breathing, producing a grating, scratchy sound. The nurse will typically hear this sound best on inspiration or expiration and it is the hallmark sign of pleuritis. The presence of a friction rub indicates the pleural inflammation characteristic of this condition.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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