Question 1

Percussion over an area of atelectasis in the lungs reveals:

Accepted Answer

A) dullness. 
B) tympany. 
C) resonance. 
D) hyperresonance. 
A) dullness. 
B) tympany. 
C) resonance. 
D) hyperresonance. A

Question 2

When assessing the respiratory system of a 4-year-old child,which of the following findings would the nurse expect?

Accepted Answer

A) Crepitus palpated at the costochondral junctions 
B) No diaphragmatic excursion as a result of decreased inspiratory volume 
C) The presence of bronchovesicular breath sounds in the peripheral lung fields 
D) An irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest 
A) Crepitus palpated at the costochondral junctions 
B) No diaphragmatic excursion as a result of decreased inspiratory volume 
C) The presence of bronchovesicular breath sounds in the peripheral lung fields 
D) An irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest C

Question 3

Bronchophony heard upon auscultation is associated with:

Accepted Answer

A) pneumothorax. 
B) hyperresonance. 
C) increased lung density. 
D) decreased breath sounds. 
A) pneumothorax. 
B) hyperresonance. 
C) increased lung density. 
D) decreased breath sounds. C

Question 4

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which of the following actions by the nurse is most appropriate?

Accepted Answer

A) Obtain a detailed history of the patient's allergies and asthma. 
B) Tell the patient to sleep on his or her right side to facilitate ease of respiration. 
C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. 
D) Reassure the patient that this is normal and will probably resolve within the next week. 
A) Obtain a detailed history of the patient's allergies and asthma. 
B) Tell the patient to sleep on his or her right side to facilitate ease of respiration. 
C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. 
D) Reassure the patient that this is normal and will probably resolve within the next week.

Question 5

The nurse notes hyperresonant tones when percussing the thorax of an infant.The nurse's best action would be to:

Accepted Answer

A) notify the physician. 
B) suspect a pneumothorax. 
C) consider this a normal finding. 
D) monitor the infant's respiratory rate and rhythm. 
A) notify the physician. 
B) suspect a pneumothorax. 
C) consider this a normal finding. 
D) monitor the infant's respiratory rate and rhythm.

Question 6

MATCHING
The nurse is evaluating voice sounds during respiratory assessment.Match the assessment with the correct technique.

-The person says "ninety-nine" repeatedly while the chest wall is being auscultated.Normally,a sound will be heard,but the examiner will not be able to distinguish exactly what is being said.

Accepted Answer

A) Bronchophony 
B) Egophony 
C) Whispered pectoriloquy 
A) Bronchophony 
B) Egophony 
C) Whispered pectoriloquy

Question 7

While auscultating for breath sounds,the nurse will use the stethoscope correctly by:

Accepted Answer

A) listening to at least one full respiration in each location. 
B) listening as the patient inhales and then going to the next site during exhalation. 
C) having the patient breathe in and out rapidly while listening to the breath sounds. 
D) listening to sounds through clothing or the hospital gown if the patient is shy. 
A) listening to at least one full respiration in each location. 
B) listening as the patient inhales and then going to the next site during exhalation. 
C) having the patient breathe in and out rapidly while listening to the breath sounds. 
D) listening to sounds through clothing or the hospital gown if the patient is shy.

Question 8

MATCHING
The nurse is evaluating voice sounds during respiratory assessment.Match the assessment with the correct technique.

-While the patient makes a long "ee-ee-ee" sound,a long "aaaaaa" sound may be noted over areas of consolidation.

Accepted Answer

A) Bronchophony 
B) Egophony 
C) Whispered pectoriloquy 
A) Bronchophony 
B) Egophony 
C) Whispered pectoriloquy

Question 9

The nurse is aware that tactile fremitus is produced by:

Accepted Answer

A) moisture in the alveoli. 
B) air in the subcutaneous tissues. 
C) sounds generated from the larynx. 
D) blood flow through the pulmonary arteries. 
A) moisture in the alveoli. 
B) air in the subcutaneous tissues. 
C) sounds generated from the larynx. 
D) blood flow through the pulmonary arteries.

Question 10

When inspecting the anterior chest of an adult,the nurse should assess for:

Accepted Answer

A) diaphragmatic excursion. 
B) symmetrical chest expansion. 
C) the presence of breath sounds. 
D) the shape and configuration of the chest wall. 
A) diaphragmatic excursion. 
B) symmetrical chest expansion. 
C) the presence of breath sounds. 
D) the shape and configuration of the chest wall.

Question 11

A mother brings her 3-month-old infant with a cold to the clinic.The mother tells the nurse that the baby has had "a runny nose for a week." When performing the physical assessment,the nurse notes that the child has nasal flaring as well as sternal and intercostal retractions.The nurse's next action should be to:

Accepted Answer

A) reassure the mother that these are normal symptoms of a cold. 
B) recognize that these are serious signs and contact the physician. 
C) recognize that these are symptoms of rachitic rosary and refer the infant to be seen by a physician within the week. 
D) perform a complete cardiac assessment because these are probably signs of early heart failure. 
A) reassure the mother that these are normal symptoms of a cold. 
B) recognize that these are serious signs and contact the physician. 
C) recognize that these are symptoms of rachitic rosary and refer the infant to be seen by a physician within the week. 
D) perform a complete cardiac assessment because these are probably signs of early heart failure.

Question 12

A patient complains of a cough that is worse at night.The nurse recognizes that this may indicate:

Accepted Answer

A) pneumonia. 
B) postnasal drip or sinusitis. 
C) exposure to irritants at work. 
D) chronic bronchial irritation due to smoking. 
A) pneumonia. 
B) postnasal drip or sinusitis. 
C) exposure to irritants at work. 
D) chronic bronchial irritation due to smoking.

Question 13

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty breathing while working in his yard.Assessment findings include tachypnea,use of accessory neck muscles,prolonged expiration,intercostal retractions,decreased breath sounds,and expiratory wheezes.This description is consistent with:

Accepted Answer

A) asthma. 
B) atelectasis. 
C) lobar pneumonia. 
D) congestive heart failure. 
A) asthma. 
B) atelectasis. 
C) lobar pneumonia. 
D) congestive heart failure.

Question 14

The primary muscles of respiration include the:

Accepted Answer

A) diaphragm and intercostals. 
B) sternomastoids and scaleni. 
C) trapezius and rectus abdominis. 
D) external obliques and pectoralis major. 
A) diaphragm and intercostals. 
B) sternomastoids and scaleni. 
C) trapezius and rectus abdominis. 
D) external obliques and pectoralis major.

Question 15

In which of the following would fine crackles most likely be noted during auscultation?

Accepted Answer

A) In a healthy 5-year-old child 
B) In the pregnant patient 
C) In the immediate newborn period 
D) In association with a pneumothorax 
A) In a healthy 5-year-old child 
B) In the pregnant patient 
C) In the immediate newborn period 
D) In association with a pneumothorax

Question 16

During auscultation of the lungs,the nurse is aware that decreased breath sounds would most likely be heard:

Accepted Answer

A) when the bronchial tree is obstructed. 
B) when adventitious sounds are present. 
C) in conjunction with whispered pectoriloquy. 
D) in conditions of consolidation,such as pneumonia. 
A) when the bronchial tree is obstructed. 
B) when adventitious sounds are present. 
C) in conjunction with whispered pectoriloquy. 
D) in conditions of consolidation,such as pneumonia.

Question 17

Which of the following describes normal changes in the respiratory system of the older adult?

Accepted Answer

A) Severe dyspnea is experienced on exertion as a result of age-related changes in the lungs. 
B) Respiratory muscle strength increases to compensate for decreased vital capacity. 
C) There is a decrease in small-airway closure,leading to problems with atelectasis. 
D) The lungs are less elastic and distensible,decreasing their ability to collapse and recoil. 
A) Severe dyspnea is experienced on exertion as a result of age-related changes in the lungs. 
B) Respiratory muscle strength increases to compensate for decreased vital capacity. 
C) There is a decrease in small-airway closure,leading to problems with atelectasis. 
D) The lungs are less elastic and distensible,decreasing their ability to collapse and recoil.

Question 18

When performing respiratory assessment on a patient,the nurse notes a costal angle of approximately 90 degrees.This characteristic is:

Accepted Answer

A) seen in patients with kyphosis. 
B) indicative of pectus excavatum. 
C) a normal finding in a healthy adult. 
D) an expected finding in a patient with a "barrel chest." 
A) seen in patients with kyphosis. 
B) indicative of pectus excavatum. 
C) a normal finding in a healthy adult. 
D) an expected finding in a patient with a "barrel chest."

Question 19

A normal finding when assessing the respiratory system of an older adult is:

Accepted Answer

A) increased thoracic expansion. 
B) decreased mobility of the thorax. 
C) a decreased anteroposterior diameter. 
D) bronchovesicular breath sounds throughout the lungs. 
A) increased thoracic expansion. 
B) decreased mobility of the thorax. 
C) a decreased anteroposterior diameter. 
D) bronchovesicular breath sounds throughout the lungs.

Question 20

The nurse has noted unequal chest expansion and is aware that this occurs when:

Accepted Answer

A) the patient is obese. 
B) part of the lung is obstructed or collapsed. 
C) bulging of the intercostal spaces is present. 
D) accessory muscles are used to augment respiratory effort. 
A) the patient is obese. 
B) part of the lung is obstructed or collapsed. 
C) bulging of the intercostal spaces is present. 
D) accessory muscles are used to augment respiratory effort.

Exam 19: Thorax and Lungs

Percussion over an area of atelectasis in the lungs reveals:

When assessing the respiratory system of a 4-year-old child,which of the following findings would the nurse expect?

Bronchophony heard upon auscultation is associated with:

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which of the following actions by the nurse is most appropriate?

The nurse notes hyperresonant tones when percussing the thorax of an infant.The nurse's best action would be to:

While auscultating for breath sounds,the nurse will use the stethoscope correctly by:

MATCHING The nurse is evaluating voice sounds during respiratory assessment.Match the assessment with the correct technique. -While the patient makes a long "ee-ee-ee" sound,a long "aaaaaa" sound may be noted over areas of consolidation.

The nurse is aware that tactile fremitus is produced by:

When inspecting the anterior chest of an adult,the nurse should assess for:

A patient complains of a cough that is worse at night.The nurse recognizes that this may indicate:

The primary muscles of respiration include the:

In which of the following would fine crackles most likely be noted during auscultation?

During auscultation of the lungs,the nurse is aware that decreased breath sounds would most likely be heard:

Which of the following describes normal changes in the respiratory system of the older adult?

When performing respiratory assessment on a patient,the nurse notes a costal angle of approximately 90 degrees.This characteristic is:

A normal finding when assessing the respiratory system of an older adult is:

The nurse has noted unequal chest expansion and is aware that this occurs when:

Critical Thinking and Evidence-Informed Assessment

Health Promotion in the Context of Health Assessment

Cultural Competence: Cultural Care and Social Considerations in Health Assessment

The Interview

The Complete Health History

Mental Health Assessment

Substance Use in the Context of Health Assessment

Interpersonal Violence Assessment

Assessment Techniques and the Clinical Setting

General Survey, measurement, and Vital Signs

Pain Assessment

Nutritional Assessment and Nursing Practice

Skin, hair, and Nails

Head and Neck, including Regional Lymphatic System

Eyes

Ears

Nose, mouth, and Throat

Breasts and Regional Lymphatic System

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Anus,rectum and Prostate

Musculoskeletal System

Neurological System

Male Genitourinary System

Female Genitourinary System

The Complete Health Assessment: Putting It All Together

Bedside Assessment of the Hospitalized Patient

Pregnancy

Functional Assessment of the Older Adult

Filters