Nokea
A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?
- A. The pons
- B. The frontal lobe
- C. Central sulcus
- D. Wernicke's area
Correct Answer: A
Rationale: The inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.
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The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?
- A. In the supine position
- B. Lying on the unaffected side
- C. In the high Fowler's position
- D. Prone with a pillow under the head
Correct Answer: B
Rationale: Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.
A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates improvement in an area of the lung affected by the infection?
- A. Lung fields documented as clear.
- B. Palpable vibrations over the chest wall when the client speaks.
- C. Decreased fremitus when the client feels the vibration in their chest.
- D. Dull sounds percussed over the lung tissue.
- E. Bronchial sounds heard only in the affected area.
Correct Answer: A
Rationale: To determine if the client's respiratory infection has resolved, the nurse should assess the client's normal respiratory status. Lungs will return to clear breath sounds. Palpable vibrations will be felt ,as they may be normal if there is no infection in the lungs. A client with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe. A decreased fremitus would indicate resolution of infection. Bronchial sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks '99.' Dull percussed sounds indicate an area of consolidation or infection.
What happens to the diaphragm during inspiration?
- A. It relaxes and raises.
- B. It contracts and flattens.
- C. It relaxes and flattens.
- D. It contracts and raises.
Correct Answer: B
Rationale: During inspiration, the diaphragm contracts and flattens, which expands the thoracic cage and increases the thoracic cavity.
The nurse is suctioning a client who is unable to expectorate respiratory secretions. At which point does the nurse expect the client to experience coughing?
- A. When the catheter reaches the back of the pharynx
- B. When the catheter enters the main bronchus of the lung
- C. When the catheter reaches the point of the carina
- D. When the catheter tickles the uvula
Correct Answer: C
Rationale: Upon the catheter stimulating the carina, coughing and even bronchospasm may occur. Productive secretions may be loosened and eliminated via the suction catheter. When the catheter reaches the back of the pharynx near the uvula, the gag reflex is initiated. The suction catheter does not reach the entrance of the lung.
The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?
- A. Watery sputum
- B. Loss of consciousness
- C. Respiratory distress
- D. Masses in pleural space
Correct Answer: C
Rationale: After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.