A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

Wheezes

Crackles

Rhonchi

Stridor

Answer and Explanation

The Correct Answer is A

A. Wheezes are continuous high-pitched sounds that occur during expiration (or sometimes inspiration) and are common in conditions like asthma due to narrowed airways.

B. Crackles are discontinuous sounds often described as popping or crackling and are not typically high-pitched.

C. Rhonchi are low-pitched, snoring-like sounds caused by the obstruction of larger airways and are not characterized as high-pitched.

D. Stridor is a high-pitched sound usually associated with upper airway obstruction and is not typically heard with asthma.

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Correct Answer is A

Explanation

A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.

B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.

C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.

D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.

A. The client has complete bilateral paralysis of the arms and legs. B. The client has lost the ability to move the right arm but is able to walk independently. C. The client has lost the ability to move the right arm but is able to walk independently. D. The client has weakness on the right side of the face and tongue. E. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance. F. The client has weakness on the right side of the body.

Correct Answer is ["D","F"]

Explanation

A. This statement indicates complete paralysis of both sides, which does not apply to hemiparesis, where one side is affected.
B. While this could describe some patients, it does not accurately represent "complete" right-sided hemiparesis.
C. This option is a repeat and also does not accurately reflect complete right-sided hemiparesis.
D. Weakness on the right side of the face and tongue is consistent with right-sided hemiparesis, as the stroke may affect motor control in those areas.
E. This describes a client who is less severely affected and may not apply to someone with complete right-sided hemiparesis.
F. Weakness on the right side of the body is a direct characteristic of right-sided hemiparesis.

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A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve II?

Correct Answer is A

Explanation

The nurse is assigned to care for a client with complete right-sided hemiparesis [weakness] from a stroke (brain attack). admitting diagnosis cerebrovascular attack Right-sided hemiparesis Which characteristics are associated with this condition? Select 2 that apply.

Correct Answer is ["D","F"]

Explanation

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