A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?

Inspection of the shape and configuration of the chest during normal breathing

Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10

Percussion of the posterior chest to initiate vibration of the lung structures

Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety nine’’

Answer and Explanation

The Correct Answer is B

A) Inspection of the shape and configuration of the chest during normal breathing:
While inspecting the shape and configuration of the chest can provide important information about potential deformities or abnormalities (such as a barrel chest or scoliosis), it does not directly assess the symmetry of chest expansion. Inspection primarily focuses on the external appearance rather than the physiological movement of the chest wall during respiration. Symmetry of chest expansion requires more than visual observation; it involves assessing the movement of the chest during inhalation and exhalation.

B) Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10:
This technique is the most effective for confirming symmetric expansion of the chest. The nurse places their hands on the patient's back, with the thumbs positioned at the level of T9 or T10, and asks the patient to take a deep breath. As the patient inhales, the nurse assesses the expansion of both sides of the chest by observing whether the thumbs move apart symmetrically. This test directly evaluates the expansion of the lungs and chest wall during respiration and is the most accurate way to assess symmetry.

C) Percussion of the posterior chest to initiate vibration of the lung structures:
Percussion is a technique used to assess the underlying lung tissue and the presence of conditions like pneumonia, fluid accumulation, or air trapping. It does not directly assess the symmetry of chest expansion. While percussion may provide valuable diagnostic information about the lungs, it does not help in determining how evenly the chest is expanding during normal breathing.

D) Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety-nine":
This technique refers to vocal fremitus, where the nurse places their hands on the client's chest while the client repeats "ninety-nine." It helps assess the transmission of sound vibrations through the chest wall, which can be used to detect areas of consolidation or fluid in the lungs. However, it does not directly evaluate the symmetry of chest expansion. The vibration felt on both sides of the chest may be different in cases of lung disease, but this test does not assess the movement of the chest during breathing.

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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. The eye focuses the image in the center of the pupil B. Constriction both pupils occurs in response to bright light C. The eye focuses the light on the sclera D. Dilation of both pupils occurs in response to bright light

Correct Answer is B

Explanation

A) The eye focuses the image in the center of the pupil:
This option describes the accommodation reflex, not the pupillary light reflex. The accommodation reflex involves the focusing of the eye to bring an image to the center of the retina, but it does not relate to the constriction of the pupils in response to light. Therefore, it is not the correct answer for describing the pupillary light reflex.

B) Constriction of both pupils occurs in response to bright light:
This is the correct description of the pupillary light reflex. When light is shined into one eye, the normal response is for both pupils (direct and consensual response) to constrict. The pupillary light reflex tests the integrity of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III), which control the constriction of the pupil in response to light. A normal pupillary light reflex is characterized by the constriction of both pupils when exposed to light.

C) The eye focuses the light on the sclera:
This statement is inaccurate. The sclera is the white part of the eye, and light is focused on the retina (specifically the fovea) for proper vision. This does not relate to the pupillary light reflex, which specifically refers to the constriction of the pupils in response to light.

D) Dilation of both pupils occurs in response to bright light:
This is incorrect. Dilation of the pupils occurs in low light conditions as part of the pupillary dilation reflex (also called the "dark reflex") to allow more light into the eye. However, in response to bright light, the pupils constrict, not dilate. The constriction of the pupils in bright light is the primary characteristic of a normal pupillary light reflex.

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A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. How should the nurse document these breath sounds in the client's medical record?

Correct Answer is A

Explanation

A nurse document that a client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

Correct Answer is B

Explanation

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