To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

Breathe in and out while all lobes of both lungs are auscultated.

Whisper "one, two, three" in sequence during auscultation of the thorax.

Repeat the number "99" during a systematic auscultation of the thorax.

Repeat vocalizing the letter "E" while the thorax is auscultated.

Answer and Explanation

The Correct Answer is D

A.   This is not specific for egophony. While lung auscultation is part of a thorough assessment, egophony is assessed when the patient vocalizes a specific sound, not just breathing in and out.
B.   This is a technique used to assess for whispered pectoriloquy, not egophony. The nurse would be looking for clarity of the whispered words, which is different from assessing for egophony.
C.   This test is used to assess for bronchophony, where the nurse listens for clarity or increased volume of spoken words over the lungs. It is not related to egophony, which is a change in the sound when the client says "E."
D.   This is the correct method for assessing egophony. In this test, the client is asked to say "E," and the nurse listens for any change in the sound. Normally, the "E" should sound like "E." If it sounds like "A," it indicates egophony, which can suggest a lung consolidation, such as might occur with a lung abscess.

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Correct Answer is D

Explanation

A. Frozen or non-movable joints typically refer to severe joint damage such as in cases of rheumatoid arthritis or advanced osteoarthritis, but Heberden's nodes are characterized by bony growths at the distal interphalangeal joints and do not indicate frozen joints.
B. Heberden's nodes are bony enlargements found at the distal interphalangeal joints. However, they are not typically associated with deviation of the joints, which might occur with other conditions like rheumatoid arthritis.
C. Proximal intertarsal joint swelling, particularly of the big toe, is more likely associated with gout, not osteoarthritis. Heberden's nodes specifically refer to changes in the distal interphalangeal joints of the fingers.
D. Heberden's nodes are typically non-painful enlargements of the distal interphalangeal joints that result from osteoarthritis. The nurse should document the presence of these nodes and note if they are non-painful.

A. Areas of tympany within the liver region. B. Tympany noted boarding the margins of the liver. C. A hollow sound over the lower abdomen. C. A dull percussion tone outside the costal margins.

Correct Answer is D

Explanation

A. Tympany indicates the presence of gas within the intestines. This would not be expected over the liver area if there is hepatomegaly.
B. This is not an expected finding in hepatomegaly. Tympany is associated with air-filled structures, which would not be present over an enlarged liver.
C. A hollow sound is also indicative of air-filled organs like the intestines. It is not a sign of hepatomegaly, which would be characterized by dullness on percussion.
D. Dullness upon percussion outside the costal margins suggests an enlarged liver (hepatomegaly). This is due to the liver becoming larger and filling the space that normally contains air-filled organs like the intestines.

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To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

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Naxlex Comprehensive Predictor Exams

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

Correct Answer is D

Explanation

While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

Correct Answer is D

Explanation

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