A client diagnosed with pleuritis has been admitted to the hospital and complains of pain with breathing. Which of the following assessment findings should the nurse expect when auscultating a client with pleuritis?

Wheezing

Friction rub

Stridor

Crackles

Answer and Explanation

The Correct Answer is B

A. Wheezing: Wheezing is a continuous, high-pitched whistling sound usually heard during expiration. It is often associated with narrowed airways, such as in asthma or chronic obstructive pulmonary disease (COPD). Wheezing occurs due to the turbulent airflow through narrowed bronchi or bronchioles and is not typically associated with pleuritis.

B. Friction rub: Pleuritis, or inflammation of the pleura, can cause a friction rub. This sound occurs when the inflamed pleural layers rub against each other during breathing. It's a grating or rubbing sound heard on auscultation and is a hallmark sign of pleuritis.

C. Stridor: Stridor is a high-pitched, harsh sound heard during inspiration and sometimes expiration. It is often a sign of upper airway obstruction, such as in croup or anaphylaxis. Stridor results from turbulent airflow through a partially obstructed or narrowed larynx or trachea.

D. Crackles: Crackles, also known as rales, are brief, discontinuous, popping sounds heard on inspiration. They can be fine or coarse and are often associated with conditions that cause fluid or secretions in the alveoli or small airways, such as pneumonia or heart failure. Crackles are not typically associated with pleuritis.

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Correct Answer is B

Explanation

A. Glandular tissue, which supports the breast by attaching to the chest wall: Glandular tissue is indeed a part of the breast structure, but it is not responsible for supporting the breast by attaching to the chest wall. It's the Cooper's ligaments, which are fibrous connective tissue, that provide structural support.

B. Fibrous, glandular, and adipose tissues: This statement is correct. The breast is composed of glandular tissue (responsible for milk production), fibrous tissue (including Cooper's ligaments for support), and adipose tissue (fat).

C. Primarily muscle with very little fibrous tissue: The breast contains very little muscle tissue. The main supportive structure is fibrous tissue, not muscle.

D. Primarily milk ducts, known as lactiferous ducts: Milk ducts are part of the glandular tissue and are responsible for carrying milk. However, the breast is not primarily made up of milk ducts; it consists of a combination of glandular, fibrous, and adipose tissues.

A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose. B. The client involuntary blinks in the presence of bright light directed over the pupils during the eye exam. C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils. D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.

Correct Answer is A

Explanation

A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose.

This statement is correct. Visual accommodation is the process by which the eye's lens changes shape to focus on objects at varying distances. When an object moves closer to the eyes, the pupils constrict to adjust and focus on the near object, preventing double vision.

B. The client involuntarily blinks in the presence of bright light directed over the pupils during the eye exam.

This statement describes the pupillary light reflex, not visual accommodation. The pupillary light reflex is the response of the pupils to light exposure.

C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.

This statement is not accurate. Peripheral vision sharpness is not related to visual accommodation. Visual accommodation mainly involves adjusting focus for objects at varying distances.

D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.

This statement is incorrect. Pupils should constrict, not dilate, when focusing on a near object (as in visual accommodation). Dilation occurs in low-light conditions or in response to sympathetic stimulation.

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A client diagnosed with pleuritis has been admitted to the hospital and complains of pain with breathing. Which of the following assessment findings should the nurse expect when auscultating a client with pleuritis?

Nursing Test Bank

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Explanation

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Explanation

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