A nurse is performing an assessment of an adult client and observes unequal chest expansion. The nurse should recognize that unequal chest expansion I occur for which reason?
When the client is obese
When part of the lung is obstructed or collapsed
When accessory muscles are used to facilitate respiratory effort
When bulging of the intercostal spaces is present
The Correct Answer is B
A) When the client is obese:
While obesity can affect the overall ease of breathing due to increased fat tissue around the chest and abdomen, it is not a direct cause of unequal chest expansion. Obesity can limit the depth of breath and potentially make it harder for the chest to expand fully, but it would not typically cause asymmetry in the movement of the chest on one side. Unequal chest expansion is more likely to occur due to underlying respiratory or structural issues.
B) When part of the lung is obstructed or collapsed:
This is the most accurate reason for unequal chest expansion. If part of the lung is obstructed (such as with a mucous plug or foreign body) or collapsed (as in the case of pneumothorax or atelectasis), it prevents that area of the lung from fully expanding during inspiration. As a result, the affected side of the chest will expand less than the opposite side. This can be a critical finding and warrants immediate further investigation to determine the cause and ensure appropriate treatment.
C) When accessory muscles are used to facilitate respiratory effort:
While the use of accessory muscles (e.g., the sternocleidomastoid, scalene, and intercostal muscles) often occurs during labored breathing, it does not specifically result in unequal chest expansion. Accessory muscle use typically occurs in conditions like severe asthma, chronic obstructive pulmonary disease (COPD), or respiratory distress, where there is an increased effort to breathe, but it doesn't cause asymmetry in the chest's movement. Unequal chest expansion is usually related to a localized problem in the lung or pleura, not the general use of muscles.
D) When bulging of the intercostal spaces is present:
Bulging of the intercostal spaces may suggest increased pressure in the pleural space, such as in the case of a pleural effusion or severe respiratory distress. However, while bulging intercostal spaces can be a sign of a respiratory condition, it is not typically associated with unequal chest expansion. Instead, bulging could indicate that the lung or chest wall is under stress or that there is fluid accumulation, which would lead to other physical findings like decreased breath sounds or dullness to percussion, but it does not directly cause unequal expansion. Unequal expansion is more likely to occur when part of the lung is obstructed or collapsed
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
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.
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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