A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Press the stethoscope's diaphragm firmly on the skin over each lung field.

Use the bell of the stethoscope to listen to the lung fields over lower lobes.

Shave all chest hair that may distort sounds heard through the diaphragm.

Have the client lay flat while listening to the anterior surface of the chest.

Answer and Explanation

The Correct Answer is A

A) Press the stethoscope's diaphragm firmly on the skin over each lung field: The diaphragm of the stethoscope is best for hearing high-pitched sounds, such as breath sounds, including adventitious lung sounds like crackles, wheezes, and rhonchi. Pressing the diaphragm firmly against the skin ensures optimal transmission of these sounds, allowing for accurate assessment of the client's lung condition.

B) Use the bell of the stethoscope to listen to the lung fields over lower lobes: The bell of the stethoscope is designed to pick up low-pitched sounds and is typically used for heart sounds and vascular sounds. It is not the best choice for auscultating breath sounds in the lungs, which are better heard with the diaphragm.

C) Shave all chest hair that may distort sounds heard through the diaphragm: While chest hair can sometimes cause distortion, it is generally not necessary to shave the chest. Instead, pressing the diaphragm firmly against the skin can help minimize interference from chest hair. If needed, the nurse can also moisten the chest hair to reduce the sound interference.

D) Have the client lay flat while listening to the anterior surface of the chest: Although certain positions can aid in auscultation, lying flat is not always necessary and can be uncomfortable for clients with respiratory issues. Sitting up or in a semi-recumbent position is generally more comfortable and effective for assessing lung sounds.

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Correct Answer is B

Explanation

A) Retracted and non-mobile tympanic membrane: This finding is typically associated with conditions such as eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described in this scenario.

B) Red, edematous ear canal with no visualization of the tympanic membrane: This description aligns with otitis externa, commonly known as "swimmer's ear." The client's history of recent swimming, itching, pain, and discharge with a musty odor are classic signs of this condition. In otitis externa, the ear canal often appears red and swollen, and the inflammation can obstruct the view of the tympanic membrane.

C) Translucent, pearly gray and mobile tympanic membrane: This appearance indicates a normal, healthy ear and is inconsistent with the symptoms of pain, itching, and discharge described by the client.

D) Thickened and bulging tympanic membrane: This finding is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum, causing it to bulge. However, it does not match the scenario of external ear canal inflammation and discharge following swimming.

A. Presents with a hacking nonproductive cough of 6 weeks duration. B. Expresses concern of "lung cancer" symptoms for last 6 weeks. C. An adult male presents with fears that he has "lung cancer." D. Describes having a "body wracking dry cough" of 6 weeks duration.

Correct Answer is D

Explanation

A) Presents with a hacking nonproductive cough of 6 weeks duration:
This documentation accurately describes the client's symptom of a cough but does not capture the client's expressed concern about the possibility of lung cancer. It is important to document the client's specific concerns and fears.

B) Expresses concern of "lung cancer" symptoms for last 6 weeks:
While this option captures the client's concern about lung cancer, it does not specifically describe the client's symptom of a dry cough. Effective documentation should include both the client's expressed concerns and the associated symptoms.

C) An adult male presents with fears that he has "lung cancer":
This option captures the client's fear of having lung cancer but does not describe the specific symptom of a dry cough that the client is experiencing. Including the specific symptom in the documentation is important for comprehensive assessment and evaluation.

D) Describes having a "body wracking dry cough" of 6 weeks duration:
This option effectively documents both the client's specific symptom (dry cough) and the duration of the symptom (6 weeks), which aligns with the client's expressed concerns. It accurately reflects the client's statement and provides valuable information for the healthcare provider's assessment and management.

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A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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