While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Report the client's abnormal lung sounds to the healthcare provider.

Ask the client to cough and then auscultate at the site again.

Measure the client's oxygen saturation with a pulse oximeter.

Continue with the remainder of the client's physical assessment.

Answer and Explanation

The Correct Answer is D

A. Vesicular breath sounds are normal lung sounds heard over most of the lung fields, including the bases. Therefore, they do not need to be reported as abnormal.
B. There is no indication that coughing is needed since the breath sounds are normal.
C. Measuring oxygen saturation is not necessary at this moment, as the vesicular sounds are a normal finding.
D. Vesicular sounds are expected, normal breath sounds in the lung bases. The nurse should continue with the remainder of the physical assessment.

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Correct Answer is B

Explanation

A. Having the client repeat a phrase containing alliteration can assess articulation and phonation but does not provide a comprehensive evaluation of overall speech patterns, including fluency, coherence, and comprehension.
B. Noting the client's responses during the initial interview is an effective way to assess speech patterns in a natural, conversational context. This approach allows the nurse to evaluate the client's language use, coherence, and any speech abnormalities.
C. Asking the client to complete a common proverb or saying can assess abstract thinking and cognitive function but is not specifically aimed at evaluating speech patterns such as fluency or coherence.
D. Listening while the client reads items listed on the menu might assess reading ability and articulation but does not provide a full assessment of conversational speech patterns or the ability to express thoughts coherently.

A. Explain to the client that an ultrasound of the breast will likely be necessary. B. Assure the client that her breasts are normal, and advise annual evaluations. C. Suggest that the client schedule a mammogram after her next menstrual period. D. Request a return visit after her menstrual period for a breast exam re-check.

Correct Answer is D

Explanation

A. While an ultrasound may be indicated if discrete masses were present or if the lumpiness persisted after menstruation, it is not necessary in this scenario where generalized lumpiness is common before menstruation.
B. Although breast tenderness and lumpiness are often normal findings related to the menstrual cycle, the nurse should not dismiss the client’s concerns without follow-up. Annual evaluations are important, but this does not address the immediate concern.
C. Mammography is generally not recommended for adolescent clients due to the density of breast tissue and the typical benign nature of breast changes in this age group.
D. Rechecking the breast exam after the client’s menstrual period is appropriate because the lumpiness and tenderness are likely related to hormonal changes and may resolve after menstruation. This approach helps differentiate normal cyclic changes from potential abnormalities.

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Joint	Type of range of motion
Shoulder - unable to move the arm away from the body	Flexion-a Adduction-a Abduction-a Extension-a
Elbow - only able to straighten joint 20 degrees	Flexion-b Adduction-b Abduction-b Extension-b
Wrist - able to bend wrist back	Flexion-c Adduction-c Abduction-c Extension-c

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Correct Answer is B

Explanation

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

Correct Answer is D

Explanation

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