The practical nurse (PN) is auscultating a client’s lung sounds and hears a high-pitched, continuous, musical sound during breathing. Which description should the PN use to document this sound?

A - The injury may require medical attention, as the mother mentioned that the boy is in pain. Correct

This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it.

The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.

B - The abrasions on the boy's leg and hand have healed.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.

C - The mother describes what she did after her child got injured.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.

D - The boy lacks coordination when answering the nurse's questions.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint.

The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inflammation.

Choice A rationale:

"Tell me about your coping strategies and support system." This is an appropriate statement during the assessment of a client with panic disorder. Understanding the client's coping mechanisms and support system can help the nurse tailor the care plan to the client's specific needs and strengths.

Choice B rationale:

"How often do you experience panic attacks and what triggers them?" While this question may be relevant, it focuses primarily on the frequency and triggers of panic attacks. While this information is important, it doesn't address coping strategies or support systems, which are equally important aspects of the assessment.

Choice C rationale:

"What medications are you currently taking for your panic disorder?" This question is essential for medication management but does not directly address coping strategies or support systems, which are more pertinent to the assessment in this context.

Choice D rationale:

"Have you ever had any laboratory tests done for your panic disorder?" This question is not relevant to the assessment of panic disorder. Panic disorder is primarily diagnosed based on clinical criteria and does not require specific laboratory tests.