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.
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Correct Answer is D
Explanation
A) Occurs only in the clinical area: Focused assessments can be conducted in various settings, including outpatient clinics, home health visits, and emergency departments. Thus, this statement does not accurately define the difference.
B) Involves all body systems: A focused assessment is specifically targeted and does not involve an evaluation of all body systems. Instead, it concentrates on particular areas of concern, making this statement incorrect.
C) Covers the body from head to toe: This describes a comprehensive assessment rather than a focused one. A comprehensive assessment is thorough and covers the entire body, while a focused assessment zeroes in on specific issues or symptoms.
D) More in depth on specific issues: A focused assessment is designed to gather detailed information about particular health problems or concerns rather than providing a broad overview of the patient’s overall health. This targeted approach allows healthcare providers to identify and address specific needs effectively, making this the correct choice.
Correct Answer is A
Explanation
A) Symmetry: During a breast inspection, the nurse should assess for symmetry between the two breasts. It is normal for there to be some slight differences, but significant asymmetry can indicate underlying issues that may need further evaluation.
B) Hard nodules: While the presence of hard nodules would be a significant finding, this would typically be assessed through palpation rather than inspection. The initial visual assessment focuses on appearance, shape, and symmetry.
C) Skin texture: Skin texture may be observed during inspection, but it is not a primary finding that stands out as a key assessment element. It can be noted as part of a comprehensive evaluation but is not the main focus.
D) Tenderness: Tenderness is a subjective assessment that is evaluated through palpation and client reporting, rather than through inspection. The nurse cannot document tenderness solely based on visual assessment.