A nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. How should the nurse document these breath sounds in the client's medical record?

Atelectatic crackles that do not have a pathologic cause

Fine crackles that may be a sign of impending pneumonia

Vesicular breath sounds

Fine wheezes

Answer and Explanation

The Correct Answer is A

A) Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation, typically occurring at the end of inspiration. These crackles are often heard in the bases of the lungs, particularly when the client is in a supine position, and are not associated with any pathological condition. Atelectatic crackles are a normal finding, especially in a sleeping or newly awakened client, as they result from the temporary collapse of small airways that quickly re-expand. Since they disappear after a few breaths and are not indicative of disease, they should be documented as atelectatic crackles without a pathological cause.

B) Fine crackles that may be a sign of impending pneumonia:
Fine crackles are high-pitched, popping sounds that are often heard during inspiration, especially at the lung bases. They are commonly associated with conditions like pneumonia, heart failure, or pulmonary fibrosis. However, in this case, the crackles heard stopped after a few breaths, which is characteristic of atelectatic crackles rather than fine crackles associated with pathological conditions. Fine crackles that last and occur consistently may suggest pathology, but in this scenario, the transient nature of the sounds points to atelectatic crackles, not pneumonia.

C) Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung fields, characterized by a soft, low-pitched sound during inspiration, with a shorter expiration. These sounds are different from crackles, which are brief, popping sounds. Vesicular breath sounds do not refer to abnormal or adventitious sounds, such as the crackles heard in this client. Therefore, the nurse should not document the breath sounds as vesicular.

D) Fine wheezes:
Wheezes are continuous musical sounds produced by the narrowing of the airways, typically heard during exhalation. They are usually caused by conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. The crackling sounds described in the question are not wheezes, as they are short, popping sounds rather than musical, continuous sounds. The transient nature of the sounds makes them more consistent with atelectatic crackles, not wheezes.

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Correct Answer is ["A","B","D","E"]

Explanation

A) High cholesterol: Elevated cholesterol levels, particularly low-density lipoprotein (LDL) cholesterol, are a significant risk factor for cardiovascular disease. High cholesterol can lead to the buildup of plaques in the arteries, which increases the risk of heart attacks and strokes. Managing cholesterol through diet, exercise, and medication can reduce cardiovascular risk.

B) Diabetes: Diabetes, especially poorly controlled blood sugar levels, significantly increases the risk of cardiovascular disease. High blood glucose can damage blood vessels and nerves, leading to complications such as coronary artery disease and stroke. Effective management of diabetes through lifestyle changes and medication can help mitigate these risks.

C) Age: While age is a risk factor for cardiovascular disease, it is a non-modifiable factor. As people age, the risk of developing cardiovascular issues naturally increases due to changes in the cardiovascular system. Since age cannot be altered, it is not included in the list of modifiable risk factors.

D) Weight: Excess body weight, particularly obesity, is associated with an increased risk of cardiovascular disease. Obesity contributes to conditions like hypertension, diabetes, and dyslipidemia, all of which elevate cardiovascular risk. Weight management through diet, exercise, and healthy lifestyle choices is crucial for reducing this risk.

E) Smoking: Smoking is a major modifiable risk factor for cardiovascular disease. It damages the blood vessels, increases blood pressure, and reduces oxygen supply to the heart, contributing to the development of atherosclerosis and other cardiovascular conditions. Quitting smoking is one of the most effective ways to lower cardiovascular risk

A. The eye focuses the image in the center of the pupil B. Constriction both pupils occurs in response to bright light C. The eye focuses the light on the sclera D. Dilation of both pupils occurs in response to bright light

Correct Answer is B

Explanation

A) The eye focuses the image in the center of the pupil:
This option describes the accommodation reflex, not the pupillary light reflex. The accommodation reflex involves the focusing of the eye to bring an image to the center of the retina, but it does not relate to the constriction of the pupils in response to light. Therefore, it is not the correct answer for describing the pupillary light reflex.

B) Constriction of both pupils occurs in response to bright light:
This is the correct description of the pupillary light reflex. When light is shined into one eye, the normal response is for both pupils (direct and consensual response) to constrict. The pupillary light reflex tests the integrity of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III), which control the constriction of the pupil in response to light. A normal pupillary light reflex is characterized by the constriction of both pupils when exposed to light.

C) The eye focuses the light on the sclera:
This statement is inaccurate. The sclera is the white part of the eye, and light is focused on the retina (specifically the fovea) for proper vision. This does not relate to the pupillary light reflex, which specifically refers to the constriction of the pupils in response to light.

D) Dilation of both pupils occurs in response to bright light:
This is incorrect. Dilation of the pupils occurs in low light conditions as part of the pupillary dilation reflex (also called the "dark reflex") to allow more light into the eye. However, in response to bright light, the pupils constrict, not dilate. The constriction of the pupils in bright light is the primary characteristic of a normal pupillary light reflex.

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A nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. How should the nurse document these breath sounds in the client's medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse s teaching a group of clients about modifiable risk factors for cardiovascular disease. Which of the following should the nurse include in the teaching? (Select All that Apply).

Correct Answer is ["A","B","D","E"]

Explanation

A nurse document that a client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

Correct Answer is B

Explanation

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