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A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment?
- A. On a scale from 1 to 10, how bad would you rate your shortness of breath?
- B. When was the last time you ate or drank anything?
- C. Are you feeling any nausea along with your shortness of breath?
- D. Do you think that some medication might help you catch your breath?
Correct Answer: A
Rationale: Gauging the severity of the patients dyspnea is an important part of the nursing process. Oral intake and nausea are much less important considerations. The nurse must perform assessment prior to interventions such as providing medication.
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A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure?
- A. The volume of air inhaled and exhaled with each breath
- B. The volume of air in the lungs after a maximal inspiration
- C. The maximal volume of air inhaled after normal expiration
- D. The maximal volume of air exhaled from the point of maximal inspiration
Correct Answer: D
Rationale: Vital capacity is measured by having the patient take in a maximal breath and exhale fully through a spirometer. Vital lung capacity is the maximal volume of air exhaled from the point of maximal inspiration, and neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the volume of air inhaled and exhaled with each breath. The volume of air in the lungs after a maximal inspiration is the total lung capacity. Inspiratory capacity is the maximal volume of air inhaled after normal expiration.
The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patients sternum. This patients health record should note the presence of what chest deformity?
- A. A barrel chest
- B. A funnel chest
- C. A pigeon chest
- D. Kyphoscoliosis
Correct Answer: B
Rationale: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax.
The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what?
- A. Nitrogen narcosis
- B. Infection
- C. Impaired diffusion
- D. Shunting
Correct Answer: D
Rationale: Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed air.
The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance?
- A. Emphysema
- B. Pulmonary fibrosis
- C. Pleural effusion
- D. Acute respiratory distress syndrome (ARDS)
Correct Answer: A
Rationale: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema. Conditions associated with decreased compliance include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and ARDS.
A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patients resonating chamber in speech?
- A. Trachea
- B. Pharynx
- C. Paranasal sinuses
- D. Larynx
Correct Answer: C
Rationale: A prominent function of the sinuses is to serve as a resonating chamber in speech. The trachea, also known as the windpipe, serves as the passage between the larynx and the bronchi. The pharynx is a tubelike structure that connects the nasal and oral cavities to the larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The major function of the larynx is vocalization through the function of the vocal cords. The vocal cords are ligaments controlled by muscular movements that produce sound.