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 B
Explanation
A. Poor electrical impulse conduction may lead to arrhythmias but does not cause a murmur.
B. A heart murmur is caused by turbulent blood flow, often through narrowed or leaking valves, creating an abnormal heart sound.
C. Left ventricular enlargement can contribute to other cardiac issues but does not directly cause murmurs.
D. Weak atrial contractions may lead to decreased cardiac output but not necessarily to a murmur.
E. While hypertension can affect the heart, it is not the direct cause of a murmur.
Correct Answer is E
Explanation
A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.