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

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.

Choice A Reason:

Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.

Choice B Reason:

Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.

Choice C Reason:

Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.

Choice D Reason:

Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.