Respiratory Assessment
During a physical assessment, the nurse remembers that the right lung has three lobes and the left lung has ______lobes to accommodate the heart.
What is:
The left lung has two lobes
Rationale:
The right lung has three lobes, while the left lung has two because the heart occupies space.
During an abdominal exam, the nurse performs this assessment step first to avoid altering bowel sounds.
What is:
Auscultation
Rationale:
The correct abdominal assessment sequence is:
Inspection → Auscultation → Percussion → Palpation.
Auscultation must occur before palpation because abdominal contact can stimulate bowel sounds.
This structure is known as the natural pacemaker of the heart and normally fires 60–100 impulses per minute.
What is:
The Sinoatrial (SA) Node
Rationale:
The SA node generates electrical impulses that initiate the cardiac cycle and control heart rhythm.
When carbohydrate intake is insufficient, the body begins using fat and protein for energy, leading to this metabolic state.
What is:
Ketosis
Rationale:
When carbohydrate intake is inadequate, the body metabolizes fat and protein for energy, leading to ketosis.
While observing a patient’s breathing, the nurse notes nasal flaring, use of accessory muscles, and a tripod position.
What is:
Signs of respiratory distress
Rationale:
Normal breathing should be quiet and effortless. Findings such as nasal flaring, accessory muscle use, and tripod positioning indicate increased work of breathing or respiratory distress.
This process moves food through the gastrointestinal tract and is controlled by the autonomic nervous system.
What is:
Peristalsis
Rationale:
Peristalsis is the rhythmic contraction of smooth muscle that moves digested material through the GI tract.
This heart sound occurs at the beginning of systole and represents the closure of the mitral and tricuspid valves.
What is:
S1
Rationale:
S1 (“lub”) occurs when the AV valves close, marking the beginning of ventricular contraction (systole).
This measurement uses height and weight to screen for underweight, overweight, or obesity.
What is:
Body Mass Index (BMI)
Rationale:
BMI is calculated using height and weight and helps identify weight categories such as underweight (<18.5), overweight (25–29.9), and obesity (≥30)
During lung auscultation, the nurse hears high-pitched whistling sounds during expiration.
What are:
Wheezes
Rationale:
Wheezes are adventitious lung sounds commonly associated with airway narrowing, such as asthma or bronchospasm.
Chapter 13 - Respiratory Assess…
A patient reports right upper quadrant abdominal pain radiating to the right scapula and has a positive Murphy’s sign.
A patient reports right upper quadrant abdominal pain radiating to the right scapula and has a positive Murphy’s sign.
A patient reports leg pain that worsens with walking but improves with rest.
What is:
Intermittent Claudication
Rationale:
Intermittent claudication is a classic symptom of Peripheral Arterial Disease (PAD) caused by decreased blood flow to the extremities during activity.
These vitamins cannot be stored in the body and must be consumed daily through diet.
What are:
Water-soluble vitamins
Rationale:
Water-soluble vitamins are not stored in the body, so they must be consumed regularly through diet.
During the respiratory assessment, the nurse notices the patient’s lips are bluish, and the fingers show clubbing.
What is:
Evidence of chronic hypoxia
Rationale:
Cyanosis and clubbing may indicate long-term oxygenation problems, suggesting chronic respiratory disease or prolonged hypoxia.
During abdominal auscultation, the nurse notes that bowel sounds occur every 5–15 seconds.
What is:
Normal bowel sounds
Rationale:
Normal bowel sounds are high-pitched gurgles occurring every 5–15 seconds. Absence must be confirmed by listening for at least 2 minutes.
During cardiac auscultation, the nurse hears an extra heart sound immediately after S2, often associated with fluid overload or heart failure
What is:
S3 Heart Sound
Rationale:
An S3 sound occurs during early diastole and may indicate heart failure or fluid volume overload, although it can be normal in children and young adults.
A patient presents with muscle wasting, loss of subcutaneous fat, and a BMI less than 18.5.
What is:
Protein-Calorie Malnutrition
Rationale:
Protein-calorie malnutrition occurs when there is inadequate intake of protein and calories, resulting in muscle wasting and underweight BMI.