After auscultating which adventitious breath sound should the nurse have the patient cough and then auscultate again?

Rhonchi.

Wheeze.

Crackles.

Stridor.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.

Choice B rationale

Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.

Choice C rationale

Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.

Choice D rationale

Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .

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Correct Answer is A

Explanation

Choice A rationale

The Angle of Louis, also known as the sternal angle, is located at the level of the 2nd intercostal space. It is a significant landmark in clinical examinations because it is used to locate important areas of the chest, such as the aortic and pulmonic areas, for auscultation.

Choice B rationale

The 3rd intercostal space is not the correct location for the Angle of Louis. The sternal angle is found at the level of the 2nd intercostal space, not the 3rd. Therefore, this option is incorrect.

Choice C rationale

The 2nd rib attaches at the level of the Angle of Louis. The sternal angle is an anatomical landmark where the manubrium and the body of the sternum meet, and it corresponds with the attachment of the 2nd rib.

Choice D rationale

The 4th intercostal space is not the correct location for the Angle of Louis. The sternal angle is located at the 2nd intercostal space, not the 4th. Therefore, this option is incorrect. .

A. Optic nerve. B. Abducens nerve. C. Hypoglossal nerve. D. Vestibulocochlear nerve.

Correct Answer is C

Explanation

Choice A rationale

The optic nerve (CN II) is responsible for vision, transmitting visual information from the retina to the brain. Dysfunction of the optic nerve would result in visual disturbances, such as loss of vision or changes in visual acuity, rather than difficulty with tongue movement. This nerve does not control motor functions of the tongue.

Choice B rationale

The abducens nerve (CN VI) controls the lateral rectus muscle of the eye, which is responsible for moving the eye outward, away from the nose. Dysfunction of the abducens nerve would result in issues with eye movement, such as double vision or inability to move the eye laterally, not tongue movement. It does not play a role in tongue motor control.

Choice C rationale

The hypoglossal nerve (CN XII) controls the muscles of the tongue, enabling movements necessary for speech, swallowing, and mastication. Dysfunction of this nerve would result in difficulty protruding the tongue and reduced strength during resistance testing. Symptoms can include atrophy of the tongue muscles, fasciculations, and deviation of the tongue to one side when extended.

Choice D rationale

The vestibulocochlear nerve (CN VIII) is responsible for hearing and balance, transmitting sound and equilibrium information from the inner ear to the brain. Dysfunction of the vestibulocochlear nerve would lead to symptoms such as hearing loss, tinnitus, or balance disorders like vertigo. It does not affect the motor control of the tongue.

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After auscultating which adventitious breath sound should the nurse have the patient cough and then auscultate again?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During cardiac examination of a client, the nurse was demonstrating to the student nurse where to locate the Angle of Louis to listen to the Aortic and Pulmonic area on the chest.The nurse should locate the Angle of Louis at the level of what rib?

Correct Answer is A

Explanation

On assessment of the client's tongue, the client is unable to protrude the tongue and has poor strength on testing against resistance.This would indicate dysfunction of which cranial nerve?

Correct Answer is C

Explanation

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