When performing a respiratory assessment on a patient, the nurse notices a costal vertebral angle (CVA) of approximately 160 degrees. How would finding?
a sign of congestive heart failure
a normal finding in a healthy adult.
seen in patients with kyphosis.
indicative of a pneumothorax.
an expected finding in a patient with a barrel chest.
The Correct Answer is C
A. CVA tenderness is associated with renal issues, not directly with congestive heart failure.
B. A CVA angle of 160 degrees is abnormal; a normal angle is closer to 90 degrees, indicating potential issues.
C. A greater CVA angle can be observed in patients with kyphosis, where the spine curves excessively, affecting rib positioning.
D. A pneumothorax typically results in reduced breath sounds and tracheal deviation, not specifically linked to CVA angle changes.
E. A barrel chest results in an increased AP diameter, not typically associated with CVA angle changes.
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Correct Answer is A
Explanation
A. Administering oxygen is crucial for clients with pneumonia, as it helps ensure adequate oxygenation, especially if respiratory function is compromised.
B. Allowing the client to choose when to eat does not directly impact the treatment of pneumonia.
C. Restricting family visits is generally not necessary unless infection control policies require it.
D. While rest is important, it is not as critical as maintaining oxygenation.
E. The location of the client in relation to the nurse’s station does not directly affect pneumonia treatment.
Correct Answer is B
Explanation
A. While posterior to anterior comparisons are used, they do not encompass the entire technique for auscultation.
B. Side-to-side comparison is the correct method as it allows for immediate assessment of differences between lung fields and helps to identify abnormal sounds effectively.
C. Interspace-by-interspace comparison is not a commonly recognized term for this method and can lead to confusion in technique.
D. Proximal to distal comparison is not specific to lung auscultation and does not effectively apply to lung assessment.
E. Top-to-bottom comparison may miss abnormalities in a specific region of the lungs; side-to-side is preferred.