Upon assessment of the lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

Wheezes

Rhonchi

Fine crackles

Vesicular sounds

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Wheezes are continuous, high-pitched, musical sounds that occur when air flows through narrowed or obstructed airways1. They can be heard during both inspiration and expiration and are commonly associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), and bronchitis. Wheezes are a key indicator of airway obstruction and require prompt medical attention to address the underlying cause.

Choice B Reason:

Rhonchi are low-pitched, continuous sounds that resemble snoring or gurgling. They are typically caused by secretions or obstructions in the larger airways. Unlike wheezes, rhonchi are not high-pitched and do not have a musical quality. They are often heard in conditions like chronic bronchitis and can sometimes be cleared with coughing.

Choice C Reason:

Fine crackles are discontinuous, high-pitched popping sounds heard during inspiration. They are caused by the sudden opening of small airways and alveoli that are collapsed or filled with fluid. Fine crackles are often associated with conditions such as pneumonia, heart failure, and pulmonary fibrosis. They are not continuous sounds and do not have the musical quality of wheezes.

Choice D Reason:

Vesicular sounds are normal breath sounds heard over most of the lung fields. They are soft, low-pitched, and rustling in quality during inspiration and are fainter during expiration. Vesicular sounds indicate normal, unobstructed airflow through the small airways and alveoli. They are not continuous or high-pitched and do not have a musical quality.

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Correct Answer is A

Explanation

Choice A Reason:

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is the most effective non-pharmacological treatment for anxiety disorders. CBT focuses on identifying and challenging negative thought patterns and behaviors that contribute to anxiety. It teaches clients practical skills to manage their anxiety, such as relaxation techniques, exposure therapy, and cognitive restructuring. Research has consistently shown that CBT can significantly reduce anxiety symptoms and improve overall functioning.

Choice B Reason:

Psychoanalytic therapy

Psychoanalytic therapy, based on the theories of Freud, aims to uncover unconscious conflicts and past experiences that influence current behavior. While it can be beneficial for some individuals, it is generally not considered the first-line treatment for anxiety disorders. Psychoanalytic therapy tends to be long-term and may not provide the immediate relief that clients with severe anxiety need.

Choice C Reason:

Electroconvulsive (ECT) therapy

Electroconvulsive therapy (ECT) involves the use of electrical currents to induce seizures in the brain and is primarily used to treat severe depression and certain other mental health conditions. It is not typically used as a treatment for anxiety disorders. ECT is considered a last-resort treatment when other therapies have failed, and it is not suitable for managing anxiety symptoms in most cases.

Choice D Reason:

Family systems therapy

Family systems therapy focuses on improving communication and relationships within the family unit. While it can be helpful for addressing family dynamics and support, it is not specifically designed to treat anxiety disorders. Family therapy may be used as an adjunct to other treatments, but it is not the primary approach for managing anxiety symptoms.

A. Have a poor prognosis. B. Are not improving and may be getting worse. C. Are questioning the hallucination and want reassurance from the nurse. D. Will begin to enter the manic phase of their illness.

Correct Answer is C

Explanation

Choice A Reason: Have a poor prognosis

A poor prognosis in schizophrenia is typically associated with persistent and severe symptoms, lack of response to treatment, and significant functional impairment. While the client’s statement about hearing voices is concerning, it does not necessarily indicate a poor prognosis on its own. Prognosis in schizophrenia is multifactorial and depends on various factors, including the duration of untreated psychosis, adherence to treatment, and the presence of supportive social networks.

Choice B Reason: Are not improving and may be getting worse

This choice suggests that the client’s condition is deteriorating. While the presence of hallucinations can indicate a lack of improvement, it is important to consider the context. The client’s ability to question the hallucination and seek reassurance from the nurse suggests a level of insight that is often associated with better outcomes. Insight into one’s condition is a positive prognostic factor in schizophrenia.

Choice C Reason: Are questioning the hallucination and want reassurance from the nurse

This is the correct answer. The client’s question indicates that they are aware that the voices might not be real and are seeking reassurance from the nurse. This level of insight is crucial in managing schizophrenia, as it can lead to better adherence to treatment and improved outcomes. Insight into the nature of hallucinations and delusions is often a sign of a more favorable prognosis.

Choice D Reason: Will begin to enter the manic phase of their illness

Mania is characterized by elevated mood, increased activity, and other symptoms such as decreased need for sleep and grandiosity. It is more commonly associated with bipolar disorder than schizophrenia. The client’s statement about hearing voices predicting their death does not align with the typical presentation of mania. Therefore, this choice is not applicable in this context.

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Upon assessment of the lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

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Naxlex Comprehensive Predictor Exams

A client diagnosed with an Anxiety Disorder tells a nurse that being in crowds creates thoughts of losing control and the need to suddenly leave. What should the nurse recommend as an effective, non-pharmacological therapy for managing the client’s symptoms of anxiety?

Correct Answer is A

Explanation

After being in the hospital for one month, a client with schizophrenia states that voices are telling them they will die tonight. The client asks the nurse if this is true. The client’s statement and question indicate that they:

Correct Answer is C

Explanation

Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?

Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?

The nurse is caring for a client with schizophrenia. Which of the following would be a priority nursing goal for this client’s care?

A nurse in orientation is rotating to a psychiatric unit where they observe a client in seclusion. Which of the following statements by the nurse’s preceptor best explains the use of seclusion on a unit?

During a morning group meeting, a client raises concern that they cannot sleep at night due to the noises coming from the nurse’s station. The nurse in the meeting interrupts and states, “I’ll handle this matter. Let’s move on.” The nurse is demonstrating which type of leadership style?

A nurse working on a mental health unit reviews therapeutic and non-therapeutic communication techniques with a student nurse. Which of the following are therapeutic communication techniques? (SELECT ALL THAT APPLY)

The nurse understands that whether or not a client experiences a crisis as a result of a stressful situation depends on:

A client was recently diagnosed with mild Alzheimer’s disease. Which of the statements shared by the client’s child about their risk for Alzheimer’s disease indicates the need for re-teaching? (Select all that apply.)