The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

As the patient says a long "ee-ee ee" sound, the examiner hears a long "aaaaaa" sound.

When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said

As the patient says a long "ee-ee-ee sound, the examiner also hears a long "ee-ee-ee" sound.

As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninetynine."

Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice

Answer and Explanation

Correct Answer : C,D

A.   As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound. - This indicates a possible consolidation in the lungs, which is abnormal.
B.   When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. - This suggests abnormal voice transmission and could indicate lung consolidation or other issues.
C.   As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. - This is normal, indicating clear and symmetrical transmission of voice sounds.
D.   As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." - This is also normal, as it indicates normal transmission of sound and no lung consolidation.
E.   Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. - This is normal for whispered voice sounds and is not a sign of abnormal lung findings.

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Correct Answer is A

Explanation

A. A herniated disc can cause pain that radiates down the leg (sciatica) when the leg is raised, along with lateral tilting of the spine as the patient attempts to relieve pressure.
B. A meniscus tear is usually associated with knee pain rather than back or leg pain.
C. Scoliosis refers to a lateral curvature of the spine but does not cause radiating leg pain as described in this case.
D. While muscle spasms can cause back pain, they are not typically associated with radiating leg pain or lateral spinal tilting.

A. Positive Romberg sign. B. Ataxia. C. Lack of coordination. D. Negative Homans sign.

Correct Answer is A

Explanation

A. A positive Romberg test occurs when a person loses balance or sways when standing with their eyes closed, indicating a problem with proprioception or balance.
B. Ataxia refers to a lack of coordination or motor control, but the Romberg sign specifically tests balance and proprioception, which is different from ataxia.
C. Lack of coordination may be part of ataxia or other neurological issues, but the Romberg sign specifically refers to balance issues when eyes are closed.
D. The Homans sign is used to test for deep vein thrombosis (DVT) and is not relevant to the test for balance and proprioception described in the scenario.

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The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, the patient complains of a pain going down his buttock into his leg. The nurse suspects:

Correct Answer is A

Explanation

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

Correct Answer is A

Explanation

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