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 B
Explanation
Choice A reason: A heart rate below normal (e.g., <60 bpm) indicates bradycardia, not necessarily arrhythmia, which is characterized by irregular rhythm. Irregular heart rate defines arrhythmia. Assuming low rate risks misdiagnosis, potentially missing treatments like antiarrhythmics, critical for stabilizing rhythm and preventing complications in arrhythmic patients.
Choice B reason: Irregular heart rate is the hallmark of arrhythmia, reflecting disrupted electrical conduction (e.g., atrial fibrillation). This sign, detected via pulse or ECG, guides diagnosis and treatment like anticoagulants or cardioversion. Accurate identification ensures timely intervention, critical for preventing stroke or heart failure in patients with cardiac rhythm disturbances.
Choice C reason: Low respiratory rate is unrelated to arrhythmia, which affects heart rhythm, not breathing. Irregular heart rate is the key sign. Assuming respiratory rate misdirects focus, risking neglect of cardiac monitoring or treatment, potentially delaying management of arrhythmia and increasing risks of thromboembolism or hemodynamic instability.
Choice D reason: Decreased blood pressure upon standing (orthostatic hypotension) is unrelated to arrhythmia, which involves irregular heart rhythm. Misidentifying this risks overlooking cardiac signs like irregular pulse, delaying ECG or antiarrhythmic therapy, critical for managing arrhythmia and preventing complications like syncope or heart failure in affected patients.
Correct Answer is D
Explanation
Choice A reason: The Snellen chart tests visual acuity (cranial nerve II), not balance, which is assessed by cranial nerve VIII via the Romberg test. Misidentifying this risks incorrect neurological evaluation, potentially missing vestibular deficits, critical for diagnosing balance disorders like vertigo or labyrinthitis in patients with cranial nerve issues.
Choice B reason: The Rinne test assesses hearing (cranial nerve VIII) by comparing air and bone conduction, not balance, which the Romberg test evaluates. Assuming Rinne tests balance misguides assessment, risking oversight of vestibular dysfunction, essential for diagnosing conditions affecting equilibrium in patients with suspected nerve VIII issues.
Choice C reason: The Weber test evaluates hearing lateralization (cranial nerve VIII), not balance, assessed by the Romberg test. Misidentifying Weber risks missing balance deficits, potentially delaying diagnosis of vestibular disorders like Meniere’s disease, critical for managing symptoms and preventing falls in patients with cranial nerve VIII dysfunction.
Choice D reason: The Romberg test assesses balance (cranial nerve VIII’s vestibular component) by evaluating posture with eyes closed, detecting vestibular or proprioceptive deficits. It’s critical for diagnosing balance disorders, guiding interventions like vestibular therapy, essential for preventing falls and managing conditions affecting equilibrium in patients with nerve VIII issues.
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