A client diagnosed with pleuritis has been admitted to the hospital and complains of pain with breathing. Which of the following assessment findings should the nurse expect when auscultating a client with pleuritis?
Wheezing
Friction rub
Stridor
Crackles
The Correct Answer is B
A. Wheezing: Wheezing is a continuous, high-pitched whistling sound usually heard during expiration. It is often associated with narrowed airways, such as in asthma or chronic obstructive pulmonary disease (COPD). Wheezing occurs due to the turbulent airflow through narrowed bronchi or bronchioles and is not typically associated with pleuritis.
B. Friction rub: Pleuritis, or inflammation of the pleura, can cause a friction rub. This sound occurs when the inflamed pleural layers rub against each other during breathing. It's a grating or rubbing sound heard on auscultation and is a hallmark sign of pleuritis.
C. Stridor: Stridor is a high-pitched, harsh sound heard during inspiration and sometimes expiration. It is often a sign of upper airway obstruction, such as in croup or anaphylaxis. Stridor results from turbulent airflow through a partially obstructed or narrowed larynx or trachea.
D. Crackles: Crackles, also known as rales, are brief, discontinuous, popping sounds heard on inspiration. They can be fine or coarse and are often associated with conditions that cause fluid or secretions in the alveoli or small airways, such as pneumonia or heart failure. Crackles are not typically associated with pleuritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation. They occur in individuals who are in a supine position and disappear after a few breaths. These crackles are not indicative of any pathological condition; they are common when the lungs are not fully aerated, especially when a person is lying down.
B. Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung areas. They are soft, low-pitched, and continuous throughout inspiration and part of expiration. Vesicular breath sounds are the typical sounds heard during routine breathing and are not associated with crackling or popping noises.
C. Fine wheezes:
Wheezes are high-pitched whistling sounds heard during expiration. They occur due to narrowed airways and are commonly associated with conditions like asthma or bronchoconstriction. Fine wheezes suggest a partial obstruction in the smaller airways, causing turbulent airflow, leading to the characteristic sound.
D. Fine crackles and may be a sign of pneumonia:
Fine crackles are high-pitched, discontinuous, crackling sounds heard during inspiration. They can occur due to the sudden opening of small airways, and their presence may indicate fluid in the lungs or lung inflammation. Fine crackles are often associated with conditions such as pneumonia, heart failure, or interstitial lung diseases.
Correct Answer is A
Explanation
A. Auricle (Pinna):
The auricle, also known as the pinna, is the visible external part of the ear. It consists of movable cartilage and skin. When administering eardrops, pulling the auricle up and back helps to straighten the ear canal, allowing the drops to enter the ear effectively.
B. Mastoid Process:
The mastoid process is a bony prominence located behind the ear. It is not a part of the outer ear structure involved in administering eardrops.
C. Outer Meatus:
The outer meatus, also known as the external acoustic meatus or ear canal, is the tube-like structure leading from the auricle to the eardrum. It is the passage through which eardrops are administered. Pulling the auricle up and back helps to straighten the outer meatus for the proper administration of eardrops.
D. Concha:
The concha refers to the bowl-shaped depression next to the ear canal. While it is a part of the outer ear, pulling the concha is not a technique used for administering eardrops. The auricle, specifically, is manipulated to facilitate the process.
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