The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?
A.
Presence of breath sounds
B.
Diaphragmatic excursion
C.
Symmetric chest expansion
D.
Shape and configuration of the chest wall
The Correct Answer and Explanation is:
The correct answer is D. Shape and configuration of the chest wall.
Explanation:
When inspecting the anterior chest of an adult client, assessing the shape and configuration of the chest wall is crucial. The normal chest shape is typically described as a symmetric, elliptical shape. Any deviations, such as barrel chest (often seen in chronic obstructive pulmonary disease), pectus excavatum (sunken chest), or pectus carinatum (pigeon chest), can indicate underlying respiratory or structural issues. Assessing the chest wall configuration can provide insights into the client’s respiratory mechanics and overall health.
Why other options are less suitable:
- A. Presence of breath sounds: While auscultation of breath sounds is essential, it is not part of the inspection. This assessment involves listening to sounds made by air moving in and out of the lungs using a stethoscope, which occurs after the visual inspection.
- B. Diaphragmatic excursion: This refers to the movement of the diaphragm during breathing and is typically assessed through percussion and measurement rather than visual inspection. This assessment provides information about the function of the diaphragm but does not fall under the inspection category.
- C. Symmetric chest expansion: Although symmetric chest expansion is an important aspect of the respiratory assessment, it is typically evaluated through palpation rather than visual inspection. This assessment involves placing hands on the client’s back to feel for equal movement of the thoracic cage during inhalation and exhalation.
In summary, while breath sounds, diaphragmatic excursion, and symmetric chest expansion are all important aspects of a respiratory assessment, they are not part of the initial visual inspection. The shape and configuration of the chest wall provide valuable information about the client’s respiratory health and should be carefully observed during the inspection phase.