The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?

Presence of breath sounds

Diaphragmatic excursion

Symmetric chest expansion

Shape and configuration of the chest wall

Answer and Explanation

The Correct Answer is D

. Presence of breath sounds: While assessing the anterior chest, the nurse should listen for breath sounds over various areas of the lungs. However, this is related to auscultation, not inspection.

B. Diaphragmatic excursion: Diaphragmatic excursion involves assessing the movement of the diaphragm during breathing. This is typically done by percussing the level where dullness changes to resonance during inhalation and exhalation. It is more related to percussion, not inspection.

C. Symmetric chest expansion: Symmetric chest expansion refers to the equal expansion of both sides of the chest during inhalation. The nurse can observe and palpate the chest to assess if it expands symmetrically on both sides. This is a crucial aspect of the inspection of the anterior chest.

D. Shape and configuration of the chest wall: The shape and configuration of the chest wall, including abnormalities or deformities, should be assessed during inspection. This includes observing for any asymmetry, deformities, masses, or scars on the anterior chest.

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Correct Answer is A

Explanation

A. AV node - SA node - bundle of His - bundle branches:

This sequence is incorrect. The SA node (sinoatrial node) initiates the electrical impulse in the heart, followed by the AV node (atrioventricular node), bundle of His, and then the bundle branches.

B. SA node - AV node - bundle of His - bundle branches:

This sequence is correct. The electrical stimulus of the cardiac cycle starts at the SA node, which is the natural pacemaker of the heart. From the SA node, the impulse travels to the AV node, then to the bundle of His, and finally to the bundle branches, which distribute the impulse to the ventricles, causing them to contract.

C. Bundle of His - AV node - SA node - Erb's Point:

This sequence is incorrect. Erb's Point is a point on the chest where heart sounds S2 and S3 can be heard most distinctly.

D. AV node - SA node - bundle of His - Erb's Point:

This sequence is incorrect. The AV node comes after the SA node in the electrical conduction system of the heart. Erb's Point is not a part of the normal cardiac conduction pathway; it is a location for auscultation on the chest.

A. Fifth left intercostal space at the midclavicular line B. Third left intercostal space at the midclavicular line C. Fourth left intercostal space at the sternal border D. Under the left breast at the midclavicular line

Correct Answer is A

Explanation

A. Fifth left intercostal space at the midclavicular line:

Explanation: The apical pulse, or the point of maximal impulse (PMI), is typically located at the fifth intercostal space at the midclavicular line on the chest. This is the area where the heartbeat is best heard using a stethoscope in most adults.

B. Third left intercostal space at the midclavicular line:

Explanation: This location is too high for the apical pulse. The heart's apex is generally not found at the third intercostal space; it's lower, closer to the fifth intercostal space.

C. Fourth left intercostal space at the sternal border:

Explanation: This location is not the typical site for auscultating the apical pulse. The PMI is usually heard at the midclavicular line, not at the sternal border.

D. Under the left breast at the midclavicular line:

Explanation: This position is not precise enough for auscultating the apical pulse. The specific intercostal space (fifth) and midclavicular line are crucial for accurate assessment.

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The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?

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