A nurse in an emergency department (ED) is admitting a client. Select 3 findings in the client's medical record that may be indicative of bronchitis.

temperature

complaint of fatigue

respiratory assessment

use of accessory muscles

blood pressure

bowel sounds

Answer and Explanation

Correct Answer : A,C,D

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.

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Correct Answer is D

Explanation

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.

A. High pitch continuous sounds on inspiration and expiration. B. High pitched short crackling C. Low pitch continuous rattling on inspiration and expiration. D. Low pitched grating and rubbing on inhalation and exhalation.

Correct Answer is A

Explanation

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.

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A nurse in an emergency department (ED) is admitting a client. Select 3 findings in the client's medical record that may be indicative of bronchitis.

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