A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Have the client lay flat while listening to the anterior surface of the chest.

Use the bell of the stethoscope to listen to the lung fields over lower lobes.

Shave all chest hair that may distort sounds heard through the diaphragm.

Press the stethoscope's diaphragm firmly on the skin over each lung field.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Having the client lay flat while listening to the anterior surface of the chest is incorrect because having the client lay flat may not be the most optimal position for auscultating lung sounds. While auscultation of the anterior surface of the chest is important, particularly for assessing the upper lobes of the lungs, having the client lay flat may not provide the best positioning for detecting all lung sounds, especially those located in the posterior lung fields.
Choice B Reason:
Using the bell of the stethoscope to listen to the lung fields over lower lobes is incorrect because using the bell of the stethoscope is more suitable for detecting low-frequency sounds such as heart murmurs or bruits. Adventitious lung sounds, such as crackles (rales) or wheezes, are typically high-pitched sounds that are best heard using the diaphragm of the stethoscope. Therefore, using the bell may not be the most effective technique for assessing adventitious lung sounds.
Choice C Reason:
Shaving all chest hair that may distort sounds heard through the diaphragm is incorrect because while removing chest hair may improve sound transmission for certain auscultatory findings, such as heart sounds, it is not specifically indicated for assessing adventitious lung sounds. Chest hair removal is not necessary for auscultation of lung sounds with the diaphragm of the stethoscope, as the sound transmission through chest hair is minimal and unlikely to significantly distort lung sounds.
Choice D Reason:
Pressing the stethoscope's diaphragm firmly on the skin over each lung field is correct because using the diaphragm of the stethoscope and pressing it firmly on the skin over each lung field ensures good contact with the chest wall, allowing for optimal transmission of lung sounds. Adventitious lung sounds, such as crackles or wheezes, are best heard using the diaphragm, particularly when it is applied firmly to the chest wall to minimize external noise and enhance sound transmission. Therefore, this technique is the most appropriate for assessing adventitious lung sounds during auscultation.

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Correct Answer is D

Explanation

Choice A Reason:
Audible thud without pain is incorrect. An audible thud without pain would not be an expected response when percussing the costovertebral angle (CVA) in a client with pyelonephritis. Pyelonephritis typically presents with tenderness upon percussion of the CVA due to inflammation or infection of the kidneys. The absence of pain in this scenario would not be consistent with the expected response.
Choice B Reason:
Rigidity and firmness are incorrect. Rigidity and firmness upon percussion of the costovertebral angle (CVA) may suggest muscle tension or guarding, rather than the tenderness typically associated with kidney inflammation or infection such as pyelonephritis. While guarding can occur in response to pain, it is not the expected response when assessing for kidney tenderness.
Choice C Reason:
Rebound tenderness is incorrect. Rebound tenderness refers to the exacerbation of pain upon release of pressure, typically observed in conditions such as peritonitis. While rebound tenderness may be present in some abdominal conditions, it is not the expected response when percussing the costovertebral angle (CVA) to assess for kidney tenderness in pyelonephritis. In pyelonephritis, tenderness upon initial percussion is more indicative of the condition.
Choice D Reason:
Sharp, severe pain is correct. Sharp, severe pain upon percussing the CVA suggests tenderness, which can be indicative of kidney inflammation or infection, such as pyelonephritis. This finding would support the diagnosis and help guide further assessment and treatment.

A. Recently had dental surgery. B. Takes an oral anticoagulant. C. Adheres to a gluten free diet. D. Works in a day care center.

Correct Answer is B

Explanation

Choice A Reason:
Recently had dental surgery is incorrect. Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising (ecchymosis) around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities. Therefore, while dental surgery may be relevant to the client's overall health history, it is less likely to directly relate to the widespread ecchymosis observed.
Choice B Reason:
Takes an oral anticoagulant is correct. Taking an oral anticoagulant medication increases the risk of bleeding, which can manifest as ecchymosis (bruising) on the skin. Anticoagulants such as warfarin or aspirin can interfere with the blood's ability to clot, leading to bleeding into the skin and subsequent ecchymosis. Therefore, this information is particularly important to follow up on as it may directly contribute to the observed ecchymosis.
Choice C Reason:
Adheres to a gluten-free diet is incorrect. Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. While celiac disease can be associated with certain skin conditions, ecchymosis is not a typical manifestation of gluten intolerance. Therefore, while this information may be relevant to the client's overall health, it is less likely to directly explain the observed ecchymosis.
Choice D Reason:
Works in a day care center is incorrect. Working in a day care center may involve activities that could result in minor injuries or bruises, but it is less likely to explain widespread ecchymosis observed on the trunk and extremities. While accidental injuries are possible in a daycare setting, they would typically be localized and not widespread. Therefore, while this information may be relevant to the client's occupation and risk of injury, it is less likely to directly relate to the observed ecchymosis.

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A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is D

Explanation

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is B

Explanation

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