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. Placing a pillow under the knees helps to relax the abdominal muscles and reduces tension during the abdominal examination.
B. Ensure adequate lighting - While good lighting is necessary for a thorough exam, it doesn't directly enhance muscle relaxation.
C. Expose the chest and abdomen for examination - Exposing the chest and abdomen is necessary for an abdominal exam but does not specifically aid in muscle relaxation.
D. Place the patient on their left side - This position is typically used for certain types of exams or procedures but does not specifically enhance muscle relaxation for an abdominal assessment.

A. Achilles reflex, which is an expected response. B. Negative Babinski sign, which is normal for adults. C. Positive Babinski sign, which is abnormal for adults. D. Clonus, which is a hyperactive response

Correct Answer is C

Explanation

A. The Achilles reflex involves the contraction of the calf muscles, not the fanning of the toes.
B. A negative Babinski sign would show the toes curling downward, which is normal for adults, not fanning out.
C. A positive Babinski sign, where the toes fan out and the big toe dorsiflexes, is abnormal in adults and typically indicates neurologic damage or dysfunction.
D. Clonus involves repeated muscle contractions, not the fanning of the toes.

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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)

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Naxlex Comprehensive Predictor Exams

To enhance muscle relaxation prior to an abdominal examination the nurse would

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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