In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Looking at the client from the side, observe the size and shape of the chest wall.

Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.

Place the palm of the hand on the chest wall to feel vibrations while the client speaks.

Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly.

Answer and Explanation

The Correct Answer is C

A) Looking at the client from the side, observe the size and shape of the chest wall:
This action is more related to inspecting the physical appearance and symmetry of the chest wall but does not assess tactile fremitus.

B) Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation:
This action may be more relevant for assessing subcutaneous emphysema (crepitus) but is not the correct method for assessing tactile fremitus.

C) Place the palm of the hand on the chest wall to feel vibrations while the client speaks:
This is the correct action to assess tactile fremitus. By placing the palm of the hand on various areas of the chest wall while the client repeats a phrase such as "ninety-nine," the nurse can feel for vibrations. Increased tactile fremitus can indicate consolidation, as seen in pneumonia.

D) Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly:
This action involves auscultation, which is important for assessing breath sounds but does not assess tactile fremitus directly.

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Correct Answer is A

Explanation

A) Intranasal edema and swelling of turbinates:
Allergic rhinitis is characterized by inflammation of the nasal mucosa in response to allergen exposure. This inflammation leads to symptoms such as nasal congestion, sneezing, and rhinorrhea. Intranasal edema and swelling of the turbinates are common findings in allergic rhinitis due to the body's immune response to allergens.

B) Eye tearing and thick yellow nasal drainage:
Eye tearing and thick yellow nasal drainage are more indicative of a bacterial infection rather than allergic rhinitis. In allergic rhinitis, nasal discharge is typically clear and watery.

C) Purulent secretions from eyes and nares:
Purulent secretions from the eyes and nares suggest a bacterial infection rather than allergic rhinitis. Allergic rhinitis typically presents with clear nasal discharge, while purulent secretions are more commonly associated with bacterial sinusitis or conjunctivitis.

D) Snoring and bilateral, pale gray nodules:
Snoring and bilateral, pale gray nodules are not characteristic findings of allergic rhinitis. Snoring may be associated with nasal congestion, but pale gray nodules are not typically observed in allergic rhinitis. These findings may indicate other nasal or upper airway conditions such as nasal polyps or adenoid hypertrophy.

A. Presents with a hacking nonproductive cough of 6 weeks duration. B. Expresses concern of "lung cancer" symptoms for last 6 weeks. C. An adult male presents with fears that he has "lung cancer." D. Describes having a "body wracking dry cough" of 6 weeks duration.

Correct Answer is D

Explanation

A) Presents with a hacking nonproductive cough of 6 weeks duration:
This documentation accurately describes the client's symptom of a cough but does not capture the client's expressed concern about the possibility of lung cancer. It is important to document the client's specific concerns and fears.

B) Expresses concern of "lung cancer" symptoms for last 6 weeks:
While this option captures the client's concern about lung cancer, it does not specifically describe the client's symptom of a dry cough. Effective documentation should include both the client's expressed concerns and the associated symptoms.

C) An adult male presents with fears that he has "lung cancer":
This option captures the client's fear of having lung cancer but does not describe the specific symptom of a dry cough that the client is experiencing. Including the specific symptom in the documentation is important for comprehensive assessment and evaluation.

D) Describes having a "body wracking dry cough" of 6 weeks duration:
This option effectively documents both the client's specific symptom (dry cough) and the duration of the symptom (6 weeks), which aligns with the client's expressed concerns. It accurately reflects the client's statement and provides valuable information for the healthcare provider's assessment and management.

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In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is D

Explanation

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