The nurse is performing the technique shown. What is the nurse assessing?
Tactile fremitus
Chest expansion
Breath sounds
Tissue consolidation
The Correct Answer is B
A. Tactile fremitus: This involves palpating vibrations on the chest wall as the patient speaks, not assessing chest expansion.
B. Chest expansion: This technique assesses the symmetrical movement of the chest during inhalation and exhalation, which is the correct assessment for this context.
C. Breath sounds: Breath sounds are assessed through auscultation rather than palpation.
D. Tissue consolidation: This involves detecting areas of increased density in lung tissue, often assessed through percussion or auscultation, not through the technique shown for chest expansion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. History of present illness: The OLD CART mnemonic is used to evaluate the characteristics of a symptom, which is documented under the history of present illness.
B. Initial Information: This section includes basic demographic and background information rather than detailed symptom analysis.
C. Review of Systems: This section includes a systematic review of body systems and their functions, not the detailed attributes of a specific symptom.
D. Health Patterns: This section covers the client’s overall health patterns and lifestyle but not the detailed attributes of a specific symptom.
Correct Answer is D
Explanation
A. External Eye Structures: This assessment involves examining the visible parts of the eye and surrounding structures, not the distance vision.
B. Near Vision: Near vision is typically assessed using a reading chart held at a close distance, not a chart mounted on the wall.
C. Peripheral Vision: Peripheral vision assessments involve testing the field of vision to detect loss or abnormalities, rather than focusing on distant vision.
D. Distant Vision: Standing 20 feet from a chart to read letters tests distant vision, as it assesses the ability to see objects clearly at a distance.
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