A senior patient is being admitted due to lobar pneumonia to the med-surgical floor. When auscultating, the nurse would expect to listen to which of the following adventitious breath sounds?

Wheezes

Rhonchi

Coarse crackles (rales)

No sound

Answer and Explanation

The Correct Answer is C

A. Wheezes: Wheezes are high-pitched sounds usually associated with airway constriction, such as in asthma, not specifically lobar pneumonia.

B. Rhonchi: Rhonchi are low-pitched, snoring sounds associated with secretions in the airways and may be present in pneumonia but are not the most characteristic finding.

C. Coarse crackles (rales): Coarse crackles or rales are bubbling, crackling sounds heard when air moves through fluid in the airways, which is typical in pneumonia due to the presence of alveolar fluid.

D. No sound: Absence of sound is not expected in pneumonia; adventitious sounds like crackles are usually present.

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Correct Answer is B

Explanation

A. Facial, Trigeminal, Vestibulocochlear: The Facial nerve (VII) is primarily responsible for facial expressions and taste sensation. The Trigeminal nerve (V) is involved in facial sensation and chewing. The Vestibulocochlear nerve (VIII) deals with hearing and balance, not eye movements.

B. Oculomotor, Trochlear, and Abducens: The Oculomotor nerve (III) controls most of the eye's movements, including constriction of the pupil. The Trochlear nerve (IV) innervates the superior oblique muscle, enabling downward and outward eye movements. The Abducens nerve (VI) controls the lateral rectus muscle, responsible for lateral eye movement.

C. Spinal Accessory, Facial, Trigeminal: The Spinal Accessory nerve (XI) controls neck and shoulder movements, not eye movements. The Facial nerve (VII) and Trigeminal nerve (V) are also not involved in eye movements.

D. Glossopharyngeal, Vagus, Hypoglossal: The Glossopharyngeal nerve (IX) is involved in taste and salivation. The Vagus nerve (X) controls parasympathetic functions and throat muscles. The Hypoglossal nerve (XII) controls tongue movements. None of these nerves are responsible for eye movements.

A. Identify ways to ensure client privacy. B. Turn on relaxing music of the client's choice. C. Wash hands D. Obtain and check needed equipment. E. Dim the lighting to promote comfort.

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

Explanation

A. Identify ways to ensure client privacy: Ensuring privacy is essential for a respectful and confidential examination.

B. Turn on relaxing music of the client's choice: While this might improve the client's comfort, it is not a standard or necessary step before conducting a physical examination.

C. Wash hands: Hand hygiene is crucial before any physical examination to prevent infection.

D. Obtain and check needed equipment: Having and checking equipment ensures that all necessary tools are available and in working order for the examination.

E. Dim the lighting to promote comfort: Proper lighting can help in conducting a thorough examination and make the client feel more comfortable.

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A senior patient is being admitted due to lobar pneumonia to the med-surgical floor. When auscultating, the nurse would expect to listen to which of the following adventitious breath sounds?

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Naxlex Comprehensive Predictor Exams

Cranial nerves involved in eye movements are:

Correct Answer is B

Explanation

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

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

Explanation

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