Week #3: Lung, Thorax, Breast & Axillae Flashcards
(49 cards)
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
a) Listen to the lungs starting in the apices
b) Instruct the client to breathe in and out rapidly through the mouth
c) Listen at one site for inspiration, then move to the next site for expiration
d) Use the diaphragm then the bell in each location
a) Listen to the lungs starting in the apices
A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump?
a) Size
b) Nipple size
c) Pallor
d) Symmetry of the chest
a) Size
A client in the ED tells a nurse that she feels short of breath. The nurse would document this finding as dyspnea.
a) True
b) False
a) True
The nurse should recognize that the presence of a wheeze can result from air passing through constricted passageways.
a) True
b) False
a) True
A nurse is inspecting a client’s nipples. Which of the following findings should the nurse regard as a cause for concern?
a) Supernumerary nipples
b) A recently retracted nipple that was previously everted
c) Nipples that are nearly equal in size
d) Nipples that have been flat for many years
b) A recently retracted nipple that was previously everted
Upon entering the exam room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would MOST likely suspect the client is compensating for what pathophysiological disorder?
a) System lupus erythematosus
b) Diabetes Mellitus
c) Chronic Obstructive Pulmonary Disease
d) Heart Failure
c) Chronic Obstructive Pulmonary Disease
What characteristic nail color should the nurse recognize as an indication of hypoxia?
a) Jaundice
b) Greenish
c) Pink
d) Cyanotic
d) Cyanotic
What techniques can be performed when palpating the breasts? Select ALL that apply:
a) Rectangular pattern
b) Wedge pattern
c) Circular pattern
d) Vertical pattern
e) Side to side pattern
b) Wedge pattern
c) Circular pattern
d) Vertical pattern
The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?
a) The lungs are structurally symmetrical but functionally differently
b) The right lung has 3 lobes, while the left lung has 2 lobes
c) The right lung is approximately 1/3 large than the left lung
d) The lower lobes of both lungs are primarily located toward the anterior chest wall
b) The right lung has 3 lobes, while the left lung has 2 lobes
The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate?
a) Palpate over the client’s own hand
b) Use the palm of one hand
c) Use the fingertips of both hands
d) Use the flat pads of 3 fingers
d) Use the flat pads of 3 fingers
Airway collapse
Atelectasis
Difficulty breathing when lying flat
Orthopnea
Unusual paleness of the skin
Pallor
Coughing up frank blood
Hemoptysis
Gray or blue skin color, indicating lack of oxygen
Cyanosis
Shortness of breath
Dyspnea
Breathing more than 24 breaths/minute
Tachypnea
normal breath sound, heard at the larynx and trachea, inspiration less than expiration
bronchial
high-pitched, soft, brief sounds that can be simulated by rolling a strand of hair near the ear; associated with HF, asthma, or COPD
fine crackles
normal breath sound, heard anteriorly between 1st and 2nd ICSs; between scapula, inspiration equal to respiration
bronchovesicular
low-pitched, moist, longer sounds similar to Velcro slowly being separated; associated with respiratory edema, COPD, and respiratory fibrosis
coarse crackles
normal breath sounds, heard over most of the lung fields; inspiration greater than expiration
vesicular
continuous, high-pitched, musical sounds caused by air squeezing through narrowed airways; associated with emphysema, asthma, and bronchitis
wheeze
continuous, low-pitched, snoring sounds resulting from secretions moving around in airways; may clear with coughing and associated with pneumonia
rhonchi
