While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

Vesicular breath sounds

Adventitious breath sounds

Bronchial breath sounds

Bronchovesicular breath sounds

Answer and Explanation

The Correct Answer is C

A. Vesicular breath sounds are soft, low-pitched sounds heard over most of the lung fields, characterized by a longer inspiratory phase and shorter expiratory phase.
B. Adventitious breath sounds refer to abnormal breath sounds such as crackles, wheezes, and rhonchi, but the described sound is a normal breath sound in the tracheal region.
C. Bronchial breath sounds are correct. These are high-pitched, harsh sounds with a short inspiratory phase and a long expiratory phase, normally heard over the trachea.
D. Bronchovesicular breath sounds are moderate in pitch and intensity, heard over the major bronchi rather than the trachea. They have equal inspiration and expiration durations rather than a longer expiratory phase.

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Correct Answer is B

Explanation

A. Ensuring valid conclusions when analyzing data is part of the initial assessment rather than the purpose of a partial assessment.
B. Reassessing previously detected problems to note any changes is correct because partial assessments are conducted to monitor the client's progress and detect any new or worsening symptoms.
C. Crisis intervention is not the primary purpose of a partial assessment unless a crisis is evident.
D. Identifying strengths and limitations in lifestyle and health status is a component of the initial comprehensive assessment rather than the partial assessment.

A. "Client's gastrointestinal health is within normal limits." B. "Gastrointestinal problems are not present at this time." C. "Client denies gastrointestinal signs and symptoms." D. "Client denies recent constipation, diarrhea, bowel incontinence or abdominal pain."

Correct Answer is D

Explanation

D. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain." is correct because it is the most specific and complete documentation of the client’s subjective report. It ensures clarity, accuracy, and thorough assessment.
A. This is incorrect because stating "within normal limits" is vague and does not specify what was assessed.
B. This is incorrect because stating "problems are not present" is too general and does not include specific symptoms the client was asked about.
C. This is incorrect because "denies gastrointestinal signs and symptoms" lacks specificity regarding which symptoms were assessed.

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While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

Correct Answer is B

Explanation

While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

Correct Answer is D

Explanation

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