Holistic Health Assessment- Respiratory Exam Practice Questions and Answers

Holistic Health Assessment- Respiratory Exam Practice Questions and Answers Position for anterior chest assessment - Answer-Client sitting or lying on their back, gown may be removed or put on backward for modesty What to assess during anterior chest inspection - Answer-Overall shape, skin color, respiratory effort and rate How should the client be positioned for a posterior chest assessment? - Answer-Sitting up with the back of the gown open or shirt off What should the nurse observe during a posterior chest assessment? - Answer-Shape and movement of the posterior thorax while the client breathes deeply Where are tracheal breath sounds heard? - Answer-Over the trachea of the anterior neck Where are bronchial breath sounds heard? - Answer-To the right and left of the trachea and larynx, auscultated over the anterior chest only Where are bronchovesicular breath sounds heard? - Answer-Over the right and left major bronchi, between the first and second intercostal space to the left and right of the sternum GRACEAMELIA 2024/2025 ACADEMIC YEAR ©2024. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER, 2024 Page 2/5 when auscultating the anterior chest, and between the scapulae and the vertebral column when auscultating the posterior chest wall Where are vesicular breath sounds auscultated? - Answer-Over the anterior and posterior chest wall, heard over a large percentage of the bilateral lung fields from the clavicle to the lower rib cage What is clubbing nails and what does it indicate? - Answer-Clubbing of the ends of the fingers or toes and a ruddy or darkish red appearance to the lower extremities are manifestations of long-term hypoxia, low oxygen levels to the tissues. What is cyanosis and how does it manifest in respiratory distress? - Answer-In respiratory distress, the skin can be cool and damp, as well as pale or blue around the lips, nail beds, and mucous membranes. What does pallor indicate in thorax and lung assessment? - Answer-General pallor can mean anemia, which can result in decreased oxygenation levels and give darker skin an ashen appearance. The client may have dyspnea (shortness of breath) and orthopnea (difficulty breathing when lying supine). What is a barrel chest and what conditions are associated with it? - Answer-A barrel chest is caused from hyperinflation of the lungs due to a disease process called chronic obstructive pulmonary disease (COPD) and can also be associated with the typical aging process. GRACEAMELIA 2024/2025 ACADEMIC YEAR ©2024. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER, 2024 Page 3/5 What is funnel chest and how does it present? - Answer-Funnel chest, or pectus excavatum, is when there is a marked sunken sternum and costal cartilage. This condition usually begins at the second intercostal space. What is pigeon chest and how does it differ from funnel chest? - Answer-A pigeon chest, or pectus carinatum, is a protrusion of the sternum with a backward sloping of the ribs. Pigeon chest should not cause any respiratory distress. What does hesitancy indicate in thorax and lung assessment? - Answer-Hesitancy can be an indication of trauma, atelectasis, guarding to reduce pain with breathing, or pneumonia. What does a grating sensation in the thorax indicate? - Answer-An indication of a pleural friction rub, requiring further investigation. What can unequal expansion in the posterior chest suggest? - Answer-Thoracic trauma like rib fractures, pneumothorax, pneumonia, or pleural inflammation. what do crackles indicate? - Answer-pneumonia or pulmonary fluid in the lungs. Describe fine crackles in abnormal breathing sounds. - Answer-Fine crackles are heard at the end of inspiration caused by partially deflated alveoli pop open, maki