Page 377 - Saunders Comprehensive Review For NCLEX-RN

cranial nerve XII (the hypoglossal
nerve) is asking the client to stick out
the tongue (should protrude in the
midline).
n. To test the gag reflex, touch the
posterior pharynx with the end of a
tongue blade; the client should gag
momentarily (this tests the function of
cranial nerve IX, the glossopharyngeal
nerve).
3. Client teaching

a. Emphasize the importance of hygiene
and tooth care, as well as regular
dental examinations and the use of
fluoridated water or fluoride
supplements.
b. Encourage the client to avoid at-risk
behaviors (e.g., smoking, alcohol
consumption).
c. Stress the importance of reporting pain
or abnormal occurrence (e.g., nodules,
lesions, signs of infection).
F. Lungs

1. Subjective data: Cough; expectoration of

sputum; shortness of breath or dyspnea; chest pain on
breathing; smoking history; environmental exposure
to pollution or chemicals; medications being taken;
history of respiratory disease or infection; last
tuberculosis test, chest radiograph, pneumonia, and
any influenza immunizations. Record the smoking
history in pack-years (the number of packs per day
times the number of years smoked). For example, a
client who has smoked one-half pack a day for 20
years has a 10-pack/year smoking history.
2. Objective data: Includes inspection, palpation,
percussion, and auscultation
3. Inspection of the anterior and posterior chest: Note
skin color and condition and the rate and quality of
respirations, look for lumps or lesions, note the shape
and configuration of the chest wall, and note the
position the client takes to breathe.
4. Palpation: Palpate the entire chest wall, noting skin
temperature and moisture and looking for areas of
tenderness and lumps, lesions, or masses; assess chest
excursion and tactile or vocal fremitus (Box 12-7).

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