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 D

Explanation

A) Review the client’s serum electrolyte:
While electrolyte imbalances can cause various neurological symptoms, including paresthesia, reviewing serum electrolytes may not directly identify additional findings consistent with the client's paresthesia. It is essential to assess electrolytes for overall health status but may not immediately address the client's reported symptoms.

B) Check distal phalanges capillary refill:
Assessing capillary refill is important for evaluating peripheral circulation and tissue perfusion, but it may not provide direct information about the client's paresthesia. Capillary refill primarily assesses vascular function rather than neurological symptoms like paresthesia.

C) Observe skin for erythema, edema, and warmth:
Observing the skin for signs of inflammation, such as erythema, edema, and warmth, is essential for assessing possible causes of paresthesia, such as inflammation or injury. However, it may not directly identify additional findings consistent with the client's reported paresthesia.

D) Evaluate client's muscle strength and hand grips:
Assessing muscle strength and hand grips can provide valuable information about neurological function and may reveal additional findings consistent with the client's paresthesia. Weakness or changes in muscle strength may accompany paresthesia, indicating potential neurological involvement. Therefore, evaluating muscle strength and hand grips is a crucial action to assess the extent and impact of the client's symptoms.

A. Telephoning a family member. B. Opening a bar soap package. C. Sorting a collection of socks. D. Reading a short paragraph.

Correct Answer is B

Explanation

Answer: B. Opening a bar soap package.

Rationale:

A) Telephoning a family member:
Using a telephone is considered an instrumental activity of daily living (IADL), which involves more complex tasks required for independent living, such as managing communication. While important, it does not directly assess the physical and motor skills required for basic self-care.

B) Opening a bar soap package:
Opening a bar soap package involves fine motor skills and hand coordination, which are necessary for performing basic activities of daily living (ADLs). ADLs refer to essential self-care tasks like bathing, dressing, and grooming. Being able to open soap indicates the client has the dexterity needed for personal hygiene.

C) Sorting a collection of socks:
Sorting socks is more cognitive than motor-oriented, and it assesses organization skills, which are more aligned with IADLs rather than ADLs. It does not specifically evaluate the client’s ability to perform tasks related to basic self-care.

D) Reading a short paragraph:
Reading a paragraph evaluates literacy or cognitive function but is not directly related to performing ADLs. ADLs focus on physical activities necessary for daily living, such as dressing, eating, or bathing.

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

Nursing Test Bank

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Explanation

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