During lung auscultation, the nurse hears a continuous low-pitched sound that resembles snoring. What is this sound called?
Crackles.
Wheezing.
Rhonchi.
Pleural friction rub.
The Correct Answer is C
Choice A reason: Crackles are discontinuous, high-pitched popping sounds heard during inspiration, often due to fluid in alveoli, as in pneumonia. The described continuous, low-pitched snoring sound indicates rhonchi, not crackles. Misidentifying crackles risks incorrect respiratory assessment, potentially delaying treatment for conditions like bronchitis requiring airway clearance or antibiotics.
Choice B reason: Wheezing is a high-pitched, musical sound caused by narrowed airways, typically in asthma or COPD, not a low-pitched snoring sound. The description matches rhonchi, indicating mucus in larger airways. Assuming wheezing misguides diagnosis, risking inappropriate bronchodilator use instead of interventions like suctioning for rhonchi-related conditions.
Choice C reason: Rhonchi are continuous, low-pitched, snoring-like sounds caused by mucus or secretions in larger airways, often in bronchitis or COPD. They may clear with coughing, matching the description. Accurate identification ensures proper interventions, like airway clearance or antibiotics, preventing complications like atelectasis or infection in patients with obstructive lung conditions.
Choice D reason: Pleural friction rub is a grating, creaking sound from inflamed pleural surfaces, not a snoring-like sound. It persists through the respiratory cycle, unlike rhonchi, which involve airway secretions. Misidentifying as a rub risks missing airway issues, delaying treatments like mucolytics, critical for managing conditions causing rhonchi in respiratory assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Vital signs are objective, measurable data, not specific to musculoskeletal assessment or subjective experience. Pain, a subjective report, better fits the question. Assuming vital signs are subjective risks misclassifying data, leading to errors in prioritizing patient-reported symptoms like pain, critical for musculoskeletal care planning and intervention.
Choice B reason: Taking NSAIDs is a factual history, not a subjective assessment. Subjective data, like pain severity, reflect patient experience. Assuming medication use is subjective misaligns with assessment principles, risking neglect of patient-reported symptoms like pain, essential for evaluating musculoskeletal conditions and guiding effective pain management strategies.
Choice C reason: Pain rated 7 to 8 is subjective, based on the patient’s personal experience, central to musculoskeletal assessment for conditions like arthritis or injury. This guides pain management, like adjusting NSAIDs. Accurate identification ensures patient-centered care, addressing discomfort and improving function, critical for musculoskeletal health outcomes.
Choice D reason: Grimacing and holding a body part are objective, observable signs, not subjective reports. Pain severity, reported by the patient, is subjective. Assuming grimacing is subjective risks misclassification, potentially overlooking patient-reported pain levels, critical for tailoring interventions like analgesics in musculoskeletal assessment and care planning.
Correct Answer is C
Explanation
Choice A reason: Head protrusions are not expected in older adults; they may indicate abnormal growths or trauma, requiring investigation. Thinning hair is a normal aging change. Assuming protrusions are expected risks missing serious conditions like tumors, delaying diagnosis and treatment critical for ensuring safety in elderly patients.
Choice B reason: Asymmetry of facial features is not a normal aging variation; it may suggest stroke or Bell’s palsy, needing urgent evaluation. Thinning hair is expected due to hormonal changes. Assuming asymmetry is normal risks overlooking neurological issues, delaying interventions critical for older adults’ health and functional outcomes.
Choice C reason: Thinning hair is an expected aging variation, resulting from reduced hair follicle activity and hormonal changes in older adults. Unlike vertigo or asymmetry, it’s benign and doesn’t require intervention unless cosmetic. Recognizing this ensures accurate assessment, focusing on abnormal findings like vertigo that need medical attention in elderly patients.
Choice D reason: Vertigo is not an expected aging variation; it may indicate inner ear disorders or neurological issues, requiring evaluation. Thinning hair is a normal change. Assuming vertigo is expected risks delaying diagnosis of treatable conditions like BPPV, compromising safety and quality of life in older adults.
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