A nurse is performing a respiratory physical examination on a healthy patient. When performing the percussion physical assessment technique, the lung percussion note should be:

Resonance

Tympanic

Flat

Dullness

Answer and Explanation

The Correct Answer is A

Choice a reason:
Resonance is the expected percussion note when percussing over normal, healthy lung tissue. This sound is produced due to the presence of air in the lung parenchyma, which allows for the transmission of sound waves through the air-filled spaces. In a healthy individual, the resonance indicates that the lungs are free from any significant abnormalities that could alter the sound, such as fluid or solid masses.
Choice b reason:
Tympanic notes are typically heard over hollow, air-containing structures like the stomach. This sound is not expected in lung percussion unless there is a large, air-filled cavity within the lung tissue, which would be abnormal and indicative of a pathological condition such as a pneumothorax.
Choice c reason:
A flat percussion note is usually heard over dense tissues where air is not present, such as over the thigh muscles or areas of the chest where lung tissue has been replaced by something more solid, like in the case of a pleural effusion or a lung mass.
Choice d reason:
Dullness on percussion usually indicates that the lung is not air-filled and may be suggestive of underlying conditions such as pneumonia, tumor, or atelectasis. It is a higher-pitched sound compared to flatness and is typically found in areas of the lung that are filled with fluid or solid tissue rather than air.

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Correct Answer is B

Explanation

Choice a reason:
Educational Prevention is not a recognized level of prevention in healthcare. While education is a key component in all levels of prevention, it is not a standalone category. Education is typically included in primary prevention as it involves informing the public about health practices to prevent the onset of disease.

Choice b reason:
Tertiary Prevention is the level of prevention that aims to manage and treat an existing disease to prevent further complications or deterioration. In the case of immobile stroke patients, tertiary prevention would involve measures to prevent skin breakdown and other complications associated with immobility and the stroke's long-term effects.

Choice c reason:
Secondary Prevention involves early detection and prompt intervention to prevent the progression of a disease. For stroke patients, secondary prevention might include monitoring for signs of skin breakdown so that early treatment can be initiated. However, the scenario described focuses on managing an existing condition rather than early detection.

Choice d reason:
Primary Prevention aims to prevent the disease or injury before it occurs. This would involve strategies to prevent strokes in the first place, such as controlling high blood pressure or encouraging healthy lifestyle changes. It does not directly relate to the prevention of skin breakdown in patients who have already had a stroke.

A. Penlight B. Gloves C. Gauze pad D. Tongue blade

Correct Answer is C

Explanation

Choice a reason:
A penlight is used to provide illumination during an examination, not to move the tongue. It helps the nurse to visualize the mouth floor and other areas by casting light, but it does not have the physical structure to manipulate the tongue.

Choice b reason:
Gloves are worn by healthcare professionals to maintain hygiene and protect both the patient and the nurse from the transmission of infectious agents. They are not used to move the tongue to one side during an examination.

Choice c reason:
A gauze pad is the correct tool to use when the nurse needs to move the tongue to one side during an examination of the mouth floor. The nurse can wrap the gauze pad around the tongue for a better grip, which allows for safe and effective retraction of the tongue without causing discomfort to the patient.

Choice d reason:
A tongue blade, also known as a tongue depressor, is typically used to depress the tongue to examine the back of the throat, not to move the tongue to one side. It is used to hold the tongue down so that the nurse can inspect the oropharynx and other structures.

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A nurse is performing a respiratory physical examination on a healthy patient. When performing the percussion physical assessment technique, the lung percussion note should be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

Correct Answer is B

Explanation

The nurse is preparing to examine a client's mouth floor. To move the tongue to one side for this examination, which tool should the nurse use?

Correct Answer is C

Explanation

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What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

The nurse is using the finger pads of the hand to palpate a body part. Which finding would the nurse be best able to detect?

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