When assessing the elderly patient, the nurse observes that the anterior to posterior width is the same as the transverse width of the chest. When documenting her findings, she describes this as:
Barrel Chest
Chronic Obstructive Pulmonary Disease
Anterior/Posterior Distortion
Lordosis
The Correct Answer is A
A) Barrel Chest: This term describes a condition where the anterior-posterior (AP) diameter of the chest is equal to the transverse diameter, giving the chest a rounded appearance. This finding is often observed in older adults or individuals with chronic respiratory conditions, and it indicates a potential increase in lung volume and air trapping, commonly seen in conditions like emphysema or chronic obstructive pulmonary disease (COPD).
B) Chronic Obstructive Pulmonary Disease: While barrel chest can be associated with COPD, it is not a direct descriptor of the chest shape. COPD encompasses various symptoms and physiological changes but does not specifically define the chest's physical appearance as barrel-shaped.
C) Anterior/Posterior Distortion: This term does not accurately describe the findings observed in the assessment. While it suggests some alteration in chest shape, it does not specifically refer to the characteristic appearance of barrel chest, which is a well-defined clinical term.
D) Lordosis: This refers to an excessive inward curve of the spine, particularly in the lumbar region. While it may affect posture and overall body alignment, it does not relate to the chest shape or measurements, making it an inappropriate choice in this context.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["A","B","C"]
Explanation
A) Blood pressure 150/90: This data is objective because it is a measurable value obtained through direct observation using a sphygmomanometer. It provides a quantifiable assessment of the client's cardiovascular status and can be verified by others, making it an important piece of objective data.
B) Bowel sounds present in all 4 quadrants: The assessment of bowel sounds is objective as it involves physical examination techniques that can be observed and documented by the nurse. The presence of bowel sounds indicates gastrointestinal activity, and this finding can be consistently assessed across different healthcare providers.
C) PERRLA: The abbreviation stands for "Pupils Equal, Round, Reactive to Light and Accommodation." This assessment is objective as it involves specific, observable measurements of the client's pupils during an eye examination. It can be consistently evaluated by different healthcare professionals, ensuring reliable documentation.
D) Anxious about surgical procedure: This statement is subjective as it reflects the client's personal feelings and emotional state. While important for understanding the client's experience, it cannot be measured or observed directly by the nurse and relies on the client's self-reporting.
E) Dyspnea on exertion: While dyspnea can be observed, the phrase "on exertion" refers to the client's subjective experience of breathlessness. Although it can be assessed through observation of respiratory patterns, the experience itself is based on the client's interpretation, making it subjective data.
Correct Answer is A
Explanation
A) Lordosis: This term specifically refers to an exaggerated inward curvature of the spine, particularly in the cervical or lumbar regions. When the nurse observes an exaggerated cervical curve, lordosis is the correct term to use for documentation, indicating a deviation from the normal spinal alignment.
B) Scoliosis: This condition is characterized by an abnormal lateral curvature of the spine. It does not apply to the observation of an exaggerated cervical curve and would not be appropriate for this finding.
C) Kyphosis: This term denotes an excessive outward curvature of the thoracic spine, often leading to a hunchback appearance. Since the assessment focuses on the cervical region, kyphosis would not accurately describe an exaggerated cervical curve.
D) Normal curve: This term refers to the expected, healthy curvature of the spine. Documenting an exaggerated curve as "normal" would be misleading and does not accurately reflect the observed condition. The nurse should document the finding as lordosis to convey the specific abnormality noted.