A. This is a diagnostic test used to determine if a client has been exposed to tuberculosis (TB). It is a secondary data source because it provides information about potential TB infection which can affect respiratory health.
B. While low socioeconomic status can impact health and access to healthcare, it is not a direct diagnostic tool or test for assessing the respiratory system. Instead, it is a social determinant that may influence health outcomes but does not provide direct data about the respiratory system itself.
C. A CBC is a laboratory test that provides information on various components of the blood, including red blood cells, white blood cells, and platelets. It can give insights into conditions that might affect the respiratory system, such as anemia or infections.
D. Male gender is a demographic characteristic rather than a diagnostic or data-gathering tool. While gender may influence the prevalence of certain respiratory conditions, it does not itself provide direct information or data about respiratory health.
E. ABG tests measure the levels of oxygen and carbon dioxide in the blood, as well as the blood’s pH balance. This test provides crucial information about a client’s respiratory function and is considered a secondary data source because it results from a specific diagnostic test rather than direct observation or physical assessment.
F. A chest x-ray is a diagnostic imaging test that provides detailed pictures of the lungs and chest cavity. It can reveal abnormalities such as infections, tumors, or fluid in the lungs. Since it is a test conducted outside of direct physical examination, it is classified as a secondary data source.

A. Wheezing is a high-pitched, musical sound produced by narrowed airways. It is a common and classic finding in asthma due to the bronchoconstriction that occurs during an asthma exacerbation. The presence of wheezing on auscultation is a strong indicator of asthma, as it reflects the turbulent airflow through constricted bronchi.
B. Normal breath sounds would generally not indicate asthma. In the absence of an asthma attack or during periods of remission, a person with asthma might have normal breath sounds. However, during an asthma exacerbation, the breath sounds are more likely to be abnormal, such as wheezing or decreased breath sounds if airflow is severely compromised.
C. Clear lung sounds on auscultation would typically indicate that there are no abnormal sounds such as wheezes, crackles, or rhonchi. In the context of asthma, clear lung sounds could be heard if the asthma is well-controlled or if the client is not currently experiencing an exacerbation.
D. A decreased respiratory rate (bradypnea) is not a typical finding in asthma. During an asthma exacerbation, clients often experience tachypnea (increased respiratory rate) due to difficulty breathing and the increased effort required to breathe.

A. While mammograms are commonly used to evaluate breast tissue in women, they are not typically used for men. In men, gynecomastia is usually evaluated with a physical exam and sometimes ultrasound rather than mammography. A mammogram might be ordered if there is a suspicion of breast cancer, but this is less common and not the first step in evaluating gynecomastia.
B. This is a prudent and effective next step. Certain medications can cause gynecomastia as a side effect, including some antipsychotics, antidepressants, antiandrogens, and calcium channel blockers. Reviewing the medication list can help identify if the gynecomastia might be related to a drug the client is taking.
C. A breast biopsy is an invasive procedure used to diagnose breast cancer or other conditions when there is a concern about a mass or abnormality. If gynecomastia is the only finding and there are no concerning features such as a palpable mass or other symptoms, a breast biopsy would not be the first step.
D. While gynecomastia can occur as a normal part of aging, especially in older men due to hormonal changes, it is important to evaluate it thoroughly to rule out other causes. Simply dismissing it as a normal part of aging without further investigation might overlook an underlying condition or medication side effect.

A. Wheezes are high-pitched, continuous sounds that occur during expiration (and sometimes inspiration) due to narrowed airways, commonly seen in conditions like asthma or chronic bronchitis. They are not typically associated with pleural inflammation.
B. This description matches a pleural friction rub. A pleural friction rub is a low-pitched, grating or rubbing sound that occurs when inflamed pleural surfaces rub against each other. It is characteristic of pleural inflammation and is best heard during both inspiration and expiration. This sound results from the roughened pleural surfaces due to inflammation and is the expected finding in a patient with pleuritis.
C. Crackles (or rales) are discontinuous, high-pitched sounds heard typically during inspiration, caused by the opening of collapsed or fluid-filled alveoli. They are commonly associated with conditions like pneumonia, congestive heart failure, or pulmonary fibrosis, rather than pleural inflammation.
D. Gurgling is not a standard term for describing lung sounds. It may refer to rhonchi, which are low- pitched, continuous sounds heard due to mucus or fluid in the larger airways. Rhonchi can be heard in conditions like bronchitis or pneumonia but are not specifically associated with pleural inflammation.

A. Thoracic muscle tenderness is not directly associated with intercostal retraction. Muscle tenderness may occur due to overuse or strain but does not cause the retraction of the intercostal spaces. It is more related to musculoskeletal issues rather than respiratory conditions.
B. Barrel chest refers to an increased anterior-posterior chest diameter, often seen in chronic obstructive pulmonary disease (COPD) and emphysema. While barrel chest can indicate chronic lung conditions that might cause respiratory distress, it does not directly cause intercostal retraction.
C. Pectus excavatum, or "funnel chest," is a congenital deformity where the sternum is depressed inward, giving the chest a sunken appearance. However, pectus excavatum itself does not directly cause retractions but can be associated with increased respiratory effort.
D. Atelectasis refers to the collapse of part or all of a lung, leading to decreased lung volume. This condition often results in increased respiratory effort and can be associated with intercostal retractions as the body struggles to expand the collapsed lung areas and improve ventilation.
E. Obstruction of the airways, such as from a foreign body, mucus plug, or severe bronchoconstriction, can lead to increased respiratory effort as the client tries to overcome the obstruction. This increased effort often results in visible signs of respiratory distress, including intercostal retraction.

A. This option describes wheezes, which are high-pitched continuous sounds often heard on both inspiration and expiration. Wheezes are commonly associated with asthma because they result from the narrowing of the airways, causing turbulent airflow.
B. This description refers to crackles (or rales), which are short, high-pitched sounds often heard on inspiration. Crackles are typically associated with conditions such as pneumonia, congestive heart failure, or other forms of pulmonary edema. They are not as specific to asthma as wheezes are.
C. This option describes rhonchi, which are low-pitched, continuous rattling sounds that may occur on both inspiration and expiration. Rhonchi are often associated with airway obstruction due to secretions or mucus and can be heard in conditions such as chronic bronchitis.
D. This option describes pleural friction rubs, which are low-pitched, grating sounds heard during both inhalation and exhalation. Pleural friction rubs occur when the pleural layers become inflamed and rub against each other.

A. Assessing the client’s respirations is crucial in evaluating their respiratory status. This includes
checking the rate, rhythm, depth, and effort of breathing. Given the client’s symptoms of cough and lung congestion, it's important to assess whether there are any signs of respiratory distress or abnormal breathing patterns.
B. Auscultating lung sounds is essential to identify any abnormal lung sounds such as wheezes, crackles, or rhonchi. This helps in evaluating the presence and severity of lung congestion and can provide insights into the underlying cause of the client's symptoms.
C. While assessing peripheral pulses is important in a comprehensive cardiovascular assessment, it is not directly related to evaluating symptoms of a cold, cough, or lung congestion. The focus of the assessment for these specific symptoms would be more on the respiratory system.
D. Checking the client’s temperature is important because a fever may indicate an infection or inflammation, which can be associated with the symptoms of a cold or lung congestion. This helps in assessing the overall systemic response to the infection.
E. A musculoskeletal and neurological examination is not directly relevant to assessing symptoms related to a cold, cough, or lung congestion. These exams are more appropriate for evaluating physical function and neurological status, which are not the primary concerns in this scenario.
F. While family history can provide valuable context for some conditions, it is not the immediate focus for evaluating current symptoms like a cold, cough, or lung congestion. The priority should be on the present symptoms and their immediate effects on the client’s health.

A. Counting respirations unobtrusively helps ensure the client does not alter their breathing pattern due to the awareness of being observed. This method is generally preferred because it provides a more accurate assessment of the client's normal respiratory rate.
B. If the client is informed that their respirations are being counted, they may unconsciously alter their breathing pattern due to nervousness or the desire to appear normal. This could result in an inaccurate assessment of their true respiratory rate.
C. Placing a hand on the client's chest can be helpful in assessing the depth and evenness of respirations. However, this method might cause the client to become aware of the assessment and could lead to a change in their breathing pattern.
D. Counting respirations only when they are audible can be problematic. Audible respirations are not always present and may not accurately reflect the client’s full respiratory rate. This method may miss periods of quiet breathing and thus provide an incomplete assessment of the respiratory rate.

A. An elevated temperature is often associated with infections and inflammation, including bronchitis. While a temperature of 99°F is slightly above normal and may indicate a mild fever, it is not a primary hallmark of bronchitis but rather a common response to infection or inflammation.
B. Fatigue is a general symptom that can accompany many conditions, including bronchitis. It is related to the overall feeling of being unwell and is not specific to bronchitis. While fatigue can be present, it is not a definitive sign of bronchitis on its own.
C. This includes findings such as bronchial breath sounds and rhonchi (a type of coarse, rattling sound) noted in the right lower lobe, which are indicative of bronchitis. The presence of rhonchi and bronchial breath sounds suggest inflammation and mucus in the airways, characteristic of bronchitis.
D. The use of accessory muscles for breathing is a sign of respiratory distress, which can occur in bronchitis when the airways are inflamed and obstructed. This finding is consistent with bronchitis as it reflects the increased effort required to breathe due to airway inflammation and mucus production.
E. The blood pressure reading of 110/54 mm Hg is within normal limits and does not provide specific information about bronchitis. Blood pressure is not typically a primary indicator for diagnosing bronchitis.
F. Bowel sounds are related to gastrointestinal function and do not provide information specific to bronchitis. Active bowel sounds are normal and do not help in diagnosing bronchitis.

A. Tachypnea refers to an increased respiratory rate. It is used when a client is breathing faster than normal. While tachypnea could be associated with difficulty breathing, it specifically denotes a faster- than-normal rate of breathing, not the sensation of breathlessness or difficulty.
B. Bradypnea is the term used for a slower-than-normal respiratory rate. If a client’s breathing rate is slower than usual, bradypnea would be the appropriate term. However, this term does not describe the sensation of shortness of breath or difficulty breathing.
C. Eupnea is the term for normal, unlabored breathing. This term is used when the client’s breathing is neither too fast nor too slow and is comfortable. It does not apply to the situation described, where the client is experiencing difficulty breathing.
D. Dyspnea refers to the sensation of shortness of breath or difficulty breathing. It is the term used to describe the subjective experience of feeling like one cannot get enough air or is having trouble breathing.