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","B","F"]

Explanation

A. Skin turgor refers to the elasticity of the skin, which can be affected by various conditions, including malignancy. The nurse should assess for any skin changes near the lump to identify any unusual signs.
B. The nurse should document the precise location of the mass, noting whether it is near the nipple or in another quadrant of the breast. This will help with future imaging and assessment.
C. While the history is important, it does not fall under objective findings that the nurse would document during the physical exam.
D. This is part of the patient’s history, not a direct observation during the physical exam, so it is not included in the documentation of objective findings of the breast mass.
E. Orientation refers to the patient’s mental status and does not relate to the characteristics of the breast mass.
F. The nurse should note the consistency of the mass (e.g., hard, firm, or soft). A firm, non-tender mass is often concerning for malignancy and should be documented.

A. When asking if the client took his medications this morning B. When determining if the client is eating a well-balanced diet C. When asking the client about his receptiveness to the transfer D. When asking the client how he completes his ADLS

Correct Answer is A

Explanation

A. Closed-ended questions are useful for obtaining specific information, such as whether the client took their medication. Yes/no responses provide clarity and a quick assessment of adherence.
B. When determining if the client is eating a well-balanced diet. Open-ended questions would be more appropriate here to gather detailed information about the client’s dietary habits.
C. When asking the client about his receptiveness to the transfer. Open-ended questions would be better for understanding the client's feelings about the transfer, as they allow the client to express their thoughts fully.
D. When asking the client how he completes his ADLs. Open-ended questions allow clients to describe their ability to perform activities of daily living, which provides a more comprehensive view of their functional abilities.

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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

Correct Answer is ["A","B","F"]

Explanation

A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors?

Correct Answer is A

Explanation

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