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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Nystagmus in extreme superior gaze: Nystagmus is an involuntary eye movement and is not a normal finding, especially in extreme superior gaze. Nystagmus can be indicative of neurological issues and requires further evaluation.

B. Slight amount of lid lag when moving the eyes from a superior to an inferior position: Lid lag refers to a delay in the downward movement of the upper eyelid during eye movement. This can be a sign of hyperthyroidism and is not a normal finding.

C. Parallel movement of both eyes: This is the correct answer. During the diagnostic positions test, the nurse should observe parallel movement of both eyes in all directions, indicating normal extraocular muscle function and coordination.

D. Convergence of the eyes: Convergence refers to the inward movement of both eyes when focusing on a close object. While convergence is a normal phenomenon, it is not specifically assessed during the diagnostic positions test, which primarily evaluates the range of motion and coordination of the extraocular muscles.

A. Checks the instrument gauge to ensure the reading starts at zero B. Centers the cuff bladder over the client's brachial artery C. Places the client's arm above the level of the client's heart D. Wraps the blood pressure cuff around the client's arm using firm pressure

Correct Answer is C

Explanation

A. Checks the instrument gauge to ensure the reading starts at zero:

This action is correct. Before taking a blood pressure reading, it's essential to ensure that the instrument's gauge starts at zero. This ensures accurate measurement as the reading reflects the pressure above zero.

B. Centers the cuff bladder over the client's brachial artery:

This action is correct. Proper placement of the blood pressure cuff over the brachial artery is crucial for accurate readings. Centering the cuff ensures that the artery is correctly compressed for measurement.

C. Places the client's arm above the level of the client's heart:

This action is incorrect. Placing the arm above heart level can result in a falsely low blood pressure reading. The arm should be at the same level as the heart to obtain an accurate measurement.

D. Wraps the blood pressure cuff around the client's arm using firm pressure:

This action is correct, but it's important to note that while the cuff should be snug, it should not be too tight or too loose. Wrapping the cuff with firm, even pressure ensures proper compression of the artery for an accurate measurement.

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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?

Nursing Test Bank

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Explanation

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