A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

Palpate the chest symmetrically

Ask the client to cough

Use the bell of the stethoscope

instruct the client to breathe deeply

Answer and Explanation

The Correct Answer is A

A) Palpate the chest symmetrically:
Palpating the chest symmetrically is crucial when assessing tactile fremitus, as it allows the nurse to compare the intensity of vibrations felt on both sides of the chest. Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary system when a person speaks or breathes. Symmetrical palpation ensures that the nurse can detect any differences in fremitus, which may indicate abnormalities such as lung consolidation (e.g., pneumonia), pleural effusion, or pneumothorax. Uneven fremitus can suggest a pathological condition, and symmetrical palpation helps identify these variations.

B) Ask the client to cough:
Asking the client to cough is not directly related to the assessment of tactile fremitus. Coughing may be used in other aspects of the respiratory assessment (e.g., to clear secretions or to assess for a productive cough), but it is not necessary for palpating fremitus. Tactile fremitus is assessed while the client is speaking (e.g., repeating the phrase "ninety-nine") or breathing, not coughing.

C) Use the bell of the stethoscope:
The bell of the stethoscope is used for auscultating low-pitched sounds, such as heart murmurs or some lung sounds (e.g., certain adventitious sounds like crackles or wheezes). However, it is not used for palpating tactile fremitus, which is a physical exam technique that involves using the hands to feel for vibrations. Fremitus is a tactile (not auscultatory) finding, so the stethoscope, whether bell or diaphragm, is not relevant in this assessment.

D) Instruct the client to breathe deeply:
While it is important for the client to breathe deeply during a lung exam, deep breathing is not directly required for assessing tactile fremitus. Tactile fremitus is typically assessed while the client is speaking. When the client repeats a phrase like "ninety-nine," vibrations are transmitted through the chest wall, and the nurse can assess the intensity of the vibrations. Deep breathing would be more relevant for assessing breath sounds or the general respiratory effort.

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Correct Answer is D

Explanation

A) A heart murmur is a high-pitched sound caused by a narrowing of a heart valve:
While it's true that a narrowing of a heart valve (stenosis) can cause a murmur, the description of a heart murmur as a "high-pitched sound" due to this narrowing is overly specific and does not fully explain what a murmur is. A murmur is not always high-pitched, and it is caused by turbulent blood flow, which may occur for various reasons beyond just valve stenosis.

B) A heart murmur is an extra sound heard from blood entering a rigid heart chamber:
This description is somewhat inaccurate. While murmurs can result from turbulent blood flow through the heart chambers or valves, the idea that murmurs are "extra sounds from blood entering a rigid heart chamber" is misleading. A murmur occurs when there is turbulent blood flow, which can happen in both rigid and non-rigid chambers. The key point is that it's the turbulent flow, not just rigidity, that causes the sound.

C) A heart murmur is a sound generated by inflammation around the heart muscle:
This is incorrect. Inflammation around the heart muscle, such as in pericarditis, can cause chest pain or other symptoms but does not generate a heart murmur. A murmur is caused by turbulent blood flow, which can result from various heart valve issues (e.g., stenosis, regurgitation) or defects in the heart's structure (e.g., septal defects), not from inflammation around the heart muscle.

D) A heart murmur indicates turbulent blood flow through a valve in the heart:
This is the most accurate description. A heart murmur is typically caused by turbulent or irregular blood flow through a heart valve. This can occur for several reasons, such as valve stenosis (narrowing), valve regurgitation (leakage), or congenital heart defects that cause abnormal flow patterns. The turbulent flow disrupts the normal laminar (smooth) blood flow, creating the characteristic sound that can be heard with a stethoscope. Murmurs can vary in timing, pitch, and intensity depending on the nature of the flow disturbance.

A. Use the Snellen chart positioned 20 feet away from the client B. Determine the client’s ability to read newsprint at a distance of 12 to 14 inches C. Perform the confrontation test D. Ask the client to read the print on a handheld jaeger card

Correct Answer is A

Explanation

A) Use the Snellen chart positioned 20 feet away from the client:
This is the correct method for assessing visual acuity in adults. The Snellen chart is the standard tool used to measure visual acuity at a distance. The client is positioned 20 feet away from the chart, and they are asked to read the smallest line of letters they can clearly identify. The result is typically documented as a fraction (e.g., 20/20), where the numerator represents the distance from the chart, and the denominator represents the distance at which a person with normal vision can read the same line. This test assesses distance vision and is essential for checking overall visual sharpness.

B) Determine the client’s ability to read newsprint at a distance of 12 to 14 inches:
This is not used to assess visual acuity; it assesses near vision and can be part of the overall vision examination, but it is not the standard method for testing visual acuity. Typically, the near vision assessment is done with tools like a Jaeger chart or by asking the client to read newsprint at a standard reading distance (12 to 14 inches), but this is not the primary test for visual acuity. The Snellen chart is specifically for distance vision.

C) Perform the confrontation test:
The confrontation test is used to assess the visual fields, not visual acuity. It is a quick screening to determine if the client has any peripheral vision loss, where the nurse and the client compare their visual fields by covering one eye at a time and identifying moving fingers in the periphery. While important, this test does not assess the sharpness or clarity of central vision, which is the focus of a visual acuity test.

D) Ask the client to read the print on a handheld Jaeger card:
The Jaeger card is used to assess near vision, not visual acuity. It is used for clients who may have difficulty reading small print at a normal reading distance and helps assess presbyopia (difficulty focusing on near objects with age). However, this test is for near vision and is not the primary test for visual acuity, which typically focuses on distance vision.

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A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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