HA MIDTERMS Flashcards
(190 cards)
1.A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?
Dyspnea
2.A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?
Severe brain damage
3.Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
Listen at each site for at least one complete respiratory cycle
4.62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer’s disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
Chronic obstructive pulmonary disease (COPD)
5.When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?
One deep inspiration and expiration through an open mouth
6.When percussing the posterior lung fields, which of the following findings is expected?
Resonance over all lung fields
7.The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?
Evaluate changes in respiratory pattern and rate
triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse’s highest priority
Patient C
9.Which terms are used to identify the lobes of the right lung? Select all that apply
upper lobe, middle lobe, lower lobe
10.The nurse is assessing a client’s breath sounds. Where should the nurse expect to hear bronchovesicular sounds?
between the scapula on the posterior chest.
11.A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is
Foreign body obstruction
12.nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?
Bradypnea
13.An adult client visits the clinic and tells the nurse that he has been “spitting up rust-colored sputum.” The nurse should refer the client to the physician for possible
Tuberculosis
14.The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
Ask the client to breathe deeply through her mouth
15.Which observation confirms to the nurse that the client is experiencing a normal inspiration?
The thoracic cavity enlarges
16.Which action by a nurse demonstrates proper technique for assessment of chest expansion?
Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse 17.are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?
Pneumonia
18.Upon inspection of a client’s chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?
chronic obstructive pulmonary disease
19.The lining of the trachea and bronchi, which serves to remove dust, foreign bodies, and bacteria, is termed the
Cilia
20.The nurse notes that a client has the thoracic structure shown. How should the nurse document this finding?
crooked upper spine: Thoracic kyphoscoliosis
21.A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client’s respiratory effort?
there is loss of involuntary respiratory control
A client reports to the nurse that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The nurse should assess this client for other findings related to what disease process?
heart failure
23.Which of the following muscles is primarily responsible for thoracic cavity enlargement?
Diaphragm
24.Auscultation of a 23-year-old client’s lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
narrowing or partial obstruction of airway passage