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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Poor dental health can be linked to hypothyroidism, as it may cause a decrease in oral health.
B. Skin should be dry and cool in hypothyroidism, making this finding abnormal.
C. Client states, "I can't seem to get warm lately." Cold intolerance is a hallmark symptom of hypothyroidism due to slowed metabolism.
D. Weight gain of five pounds in two months. Mild weight gain can occur in hypothyroidism but may not be significant enough to consider abnormal without other symptoms.
E. Periorbital non-pitting edema. This finding is common in hypothyroidism and indicates water retention around the eyes.
Correct Answer is C
Explanation
A. This is incorrect, as a patient’s expression of pain can vary significantly based on cultural, emotional, and psychological factors, not just the severity of the injury.
B. This is false. Pain expression is highly individualized and influenced by cultural and personal factors.
C. This is correct. Different cultures and individuals have varied ways of expressing pain, which can affect their pain management.
D. This is not accurate. Cultural norms play a significant role in how individuals tolerate and express pain.
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