Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

Use of accessory muscles

Nail bed greater than 160 degrees

Circumoral cyanosis

Pursed lip breathing

Anteroposterior-to-transverse diameter of 1:1

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Use of accessory muscles

Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.

B. Nail bed greater than 160 degrees

Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.

C. Circumoral cyanosis

Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.

D. Pursed lip breathing

Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.

E. Anteroposterior-to-transverse diameter of 1:1

Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.

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Correct Answer is C

Explanation

A. Bronchovesicular breath sounds and normal in that location:

Bronchovesicular breath sounds are medium-pitched sounds heard over the major bronchi and are usually equal on inspiration and expiration. They are typically heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulae posteriorly. While they might be normal in certain locations, hearing them over peripheral lung fields might indicate an abnormality.

B. Normally auscultated over the trachea:

This statement doesn't specify a particular type of breath sound. Tracheal breath sounds are harsh and relatively high-pitched, heard directly over the trachea. They are normal over the trachea but are not normally heard in the lung periphery.

C. Vesicular breath sounds and normal in that location:

Vesicular breath sounds are low-pitched, soft sounds heard over most of the lungs during inspiration. They are longer on inspiration than expiration and are considered normal breath sounds heard in the peripheral lung fields. Hearing vesicular sounds in the posterior lower lobes is typical and indicates normal lung function.

D. Bronchial breath sounds and normal in that location:

Bronchial breath sounds are high-pitched and loud, heard primarily over the trachea and larynx. If heard in the peripheral lung fields, especially in the lower lobes, it can suggest an abnormality such as consolidation or compression of lung tissue.

A. Glandular tissue, which supports the breast by attaching to the chest wall. B. Fibrous, glandular, and adipose tissues C. Primarily muscle with very little fibrous tissue. D. Primarily milk ducts, known as lactiferous ducts.

Correct Answer is B

Explanation

A. Glandular tissue, which supports the breast by attaching to the chest wall: Glandular tissue is indeed a part of the breast structure, but it is not responsible for supporting the breast by attaching to the chest wall. It's the Cooper's ligaments, which are fibrous connective tissue, that provide structural support.

B. Fibrous, glandular, and adipose tissues: This statement is correct. The breast is composed of glandular tissue (responsible for milk production), fibrous tissue (including Cooper's ligaments for support), and adipose tissue (fat).

C. Primarily muscle with very little fibrous tissue: The breast contains very little muscle tissue. The main supportive structure is fibrous tissue, not muscle.

D. Primarily milk ducts, known as lactiferous ducts: Milk ducts are part of the glandular tissue and are responsible for carrying milk. However, the breast is not primarily made up of milk ducts; it consists of a combination of glandular, fibrous, and adipose tissues.

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Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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