The nurse is listening to the breath sounds of young adult client with severe asthma. The nurse recognizes that air passing through narrowed bronchioles would produce which of these adventitious sounds?
Wheezes
Whispered pectoriloquy
Bronchial sounds
Bronchophony
The Correct Answer is A
A. Wheezes:
Wheezes are continuous, high-pitched, whistling lung sounds that are heard especially during expiration and sometimes during inspiration. They are caused by the rapid movement of air through narrowed or constricted airways, which is common in conditions like asthma. Wheezing is a characteristic adventitious sound associated with asthma and other obstructive respiratory disorders.
B. Whispered Pectoriloquy:
Whispered Pectoriloquy is an increased loudness of whispering noted during auscultation with a stethoscope on the lung fields. This phenomenon occurs when sound is transmitted clearly through consolidated or compressed lung tissue, making whispered sounds more distinct. It is a sign of lung consolidation, often seen in conditions like pneumonia.
C. Bronchial Sounds:
Bronchial sounds are harsh, high-pitched sounds heard over the trachea and the large bronchi. These sounds are normally heard during expiration. If they are heard over peripheral lung areas, it can indicate consolidation or compression of lung tissue, possibly due to pneumonia or tumor.
D. Bronchophony:
Bronchophony is a phenomenon in which spoken sounds are heard more clearly and distinctly through the stethoscope on auscultation of the lungs. Normally, sounds are muffled during auscultation. Increased clarity of spoken sounds can indicate lung consolidation, similar to whispered pectoriloquy, and is often associated with conditions like pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Simultaneously palpating both arteries to compare amplitude: While comparing amplitudes is important, using the diaphragm of the stethoscope to listen for bruits (abnormal whooshing sounds indicating turbulent blood flow) is a more specific and accurate method for assessing the carotid arteries for potential vascular issues.
B. Listening with the diaphragm of the stethoscope to assess for bruits: This technique allows the nurse to detect abnormal sounds (bruits) that could indicate partial blockages or stenosis in the carotid arteries, suggesting a risk of stroke or transient ischemic attack.
C. Instructing the patient to take slow deep breaths during auscultation: Deep breaths are more relevant during lung auscultation. Carotid artery assessment focuses on detecting abnormal sounds and assessing blood flow rather than respiratory patterns.
D. Palpating the artery at the base of the neck: Palpation alone does not provide enough information about potential blockages or abnormalities in the carotid arteries. Listening with a stethoscope allows for a more detailed assessment of blood flow and the presence of bruits.f the nurse hears a bruit during auscultation, they shouldnotpalpate the carotid artery. A bruit suggests partial obstruction (carotid stenosis), and compressing the artery further could worsen blood flow.
Correct Answer is B
Explanation
A. AV node - SA node - bundle of His - bundle branches:
This sequence is incorrect. The SA node (sinoatrial node) initiates the electrical impulse in the heart, followed by the AV node (atrioventricular node), bundle of His, and then the bundle branches.
B. SA node - AV node - bundle of His - bundle branches:
This sequence is correct. The electrical stimulus of the cardiac cycle starts at the SA node, which is the natural pacemaker of the heart. From the SA node, the impulse travels to the AV node, then to the bundle of His, and finally to the bundle branches, which distribute the impulse to the ventricles, causing them to contract.
C. Bundle of His - AV node - SA node - Erb's Point:
This sequence is incorrect. Erb's Point is a point on the chest where heart sounds S2 and S3 can be heard most distinctly.
D. AV node - SA node - bundle of His - Erb's Point:
This sequence is incorrect. The AV node comes after the SA node in the electrical conduction system of the heart. Erb's Point is not a part of the normal cardiac conduction pathway; it is a location for auscultation on the chest.
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