After auscultating which adventitious breath sound should the nurse have the patient cough and then auscultate again?
Rhonchi.
Wheeze.
Crackles.
Stridor.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The general survey is an overall assessment of a client's physical appearance, behavior, mobility, and neurological status. It provides a comprehensive overview of the client's health and well-being, making it the focus of the nurse's observations in this scenario.
Choice B rationale
Medical history includes past and current health conditions, surgeries, medications, and family health history. While important, it is not the focus of the nurse's immediate observations in this scenario.
Choice C rationale
Biographical data involves personal information such as age, gender, occupation, and marital status. While relevant to the client's health, it is not the primary focus of the nurse's observations in this scenario.
Choice D rationale
Social history includes information about the client's lifestyle, habits, and social environment. While valuable for understanding the client's overall health context, it is not the focus of the nurse's immediate observations in this scenario. .
Correct Answer is C
Explanation
Choice A rationale
Fibrocystic lesions in the breast are benign changes that involve the formation of cysts and fibrous tissue. These do not typically cause an orange-peel appearance of the skin.
Choice B rationale
A normal finding of the breast would not include an orange-peel or "peau d'orange" appearance, as this is considered an abnormal change often associated with underlying pathology.
Choice C rationale
Carcinoma of the breast can lead to an orange-peel appearance of the skin due to lymphatic obstruction. This dimpling effect is caused by the cancerous infiltration and thickening of the skin, making this the correct answer.
Choice D rationale
Fibroadenoma is a benign tumor of the breast and does not usually cause the skin changes described as orange-peel appearance. This condition is generally not associated with skin texture changes.
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