Question

5. A client has a history of chronic obstructive pulmonary disease.

A. atrophy of neck and trapezius muscles

B. unequal chest expansion

C. dullness on percussion

D. anteroposterior-to-transverse diameter ratio 1:1

6. Which of the fallowing would the nurse asses for at the 5th intercostal space midclavicular?

A. mitral stenosis

B. S3

C. aortic stenosis

D. erbs point

E. S4

7. A nurse is assessing a client who has chronic respiratory insufficiency.

A. restlessness

B. retractions

C. dependent edema

D. clubbing

8. The nurse would describe lesions that are elevated, SOLID, circumscribed lesion< 1cm in diameter

A. papules

B. wheals

C. scales

D. vesicles

9. The component of the conduction system is referred to as the pacemaker of the is the?

A. bundle of his

B. SA node

C. AV node

D. bundle of branches

10. A client is hospitalized for a left pneumothorax.

A. bulging

B. midline

C. shift to the right

D. shift to the left

Answer 1

5.atrophy of neck and trapezius muscle, in copd patient had laboured breathing, so the use acessory muscle for breathing. So the muscle wasting occurs.

Unequal chest expansion seen in atelectasis or lung collapse. Dullness seen in pneumothorax or pneumonia. Anteroposterior diameter to transverse is 1:1 is not in copd.

6.mitral stenosis is asucultated in 5th intercostal space of midclavicular line

Erbs point inthe 3rd intercostal space and lower sternal border. S3and, the S4 sound is low pitched and best heard at the apex with the patient in the left lateral decubitus position. Atrial stenosis in the lower sternal area.

7.restlessness is the main feature of respiratory insufficiency, while assessing the acute case we can find patieny may agitated because of insufficient intake of oxygen. They may have suffocation. Other features can be seen in later stage of respiratory diseases.

8.papules are raised solid skin lrsion of 1cm diameter

Wheals, raised patchy skin lesion occurs as a result of allergy. Scales are flaky and peels of the epidermis skin.vescicles are fluid filled blister in the skin

9.SA node is considered as the pacemaker of the heart.because excitation signal is created by the SA node.When an electrical impulse is released from this natural pacemaker, it causes the atria to contract.others are part of conduction system which complete the conduction system.

10.shift to the right.

In left side pneumothorax the air filled in the leftside give pressure and it cause the trachea to shift opposite side.

Left shift occurs in right side pneumothorax, median shift is not a sign of left side pneumo thorax.bulging occurs in the thoraccic cavity is the feature of inflammation of disc.