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?
Have the client lay flat while listening to the anterior surface of the chest.
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.
Press the stethoscope's diaphragm firmly on the skin over each lung field.
The Correct Answer is D
Choice A Reason:
Having the client lay flat while listening to the anterior surface of the chest is incorrect because having the client lay flat may not be the most optimal position for auscultating lung sounds. While auscultation of the anterior surface of the chest is important, particularly for assessing the upper lobes of the lungs, having the client lay flat may not provide the best positioning for detecting all lung sounds, especially those located in the posterior lung fields.
Choice B Reason:
Using the bell of the stethoscope to listen to the lung fields over lower lobes is incorrect because using the bell of the stethoscope is more suitable for detecting low-frequency sounds such as heart murmurs or bruits. Adventitious lung sounds, such as crackles (rales) or wheezes, are typically high-pitched sounds that are best heard using the diaphragm of the stethoscope. Therefore, using the bell may not be the most effective technique for assessing adventitious lung sounds.
Choice C Reason:
Shaving all chest hair that may distort sounds heard through the diaphragm is incorrect because while removing chest hair may improve sound transmission for certain auscultatory findings, such as heart sounds, it is not specifically indicated for assessing adventitious lung sounds. Chest hair removal is not necessary for auscultation of lung sounds with the diaphragm of the stethoscope, as the sound transmission through chest hair is minimal and unlikely to significantly distort lung sounds.
Choice D Reason:
Pressing the stethoscope's diaphragm firmly on the skin over each lung field is correct because using the diaphragm of the stethoscope and pressing it firmly on the skin over each lung field ensures good contact with the chest wall, allowing for optimal transmission of lung sounds. Adventitious lung sounds, such as crackles or wheezes, are best heard using the diaphragm, particularly when it is applied firmly to the chest wall to minimize external noise and enhance sound transmission. Therefore, this technique is the most appropriate for assessing adventitious lung sounds during auscultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
C. Chronic obstructive pulmonary disease (COPD): COPD is a chronic respiratory condition characterized by airflow limitation, typically caused by chronic bronchitis and/or emphysema. In COPD, the airways become narrowed and inflamed, leading to difficulty breathing. Over time, chronic hypoxia (low oxygen levels in the blood) can develop due to impaired gas exchange in the lungs. Chronic hypoxia can trigger compensatory mechanisms in the body, including vascular changes that result in clubbing of the nails. Therefore, clubbed nails can often be seen in individuals with COPD as a consequence of chronic tissue hypoxia.
D. Lung cancer: Lung cancer is a malignant tumor that arises from the cells of the lungs. It is often associated with long-term smoking, as in the case of this client. Lung cancer can impair lung function and compromise gas exchange, leading to chronic hypoxia. As with COPD, chronic hypoxia can induce vascular changes that result in clubbing of the nails. Therefore, clubbed nails can be a manifestation of advanced lung cancer, particularly in cases where chronic hypoxia is present due to impaired lung function.
E. Chronic bronchitis: Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by inflammation and narrowing of the airways, leading to excessive mucus production and persistent cough. Similar to other forms of COPD, chronic bronchitis can result in chronic hypoxia due to impaired gas exchange in the lungs. The chronic hypoxia associated with chronic bronchitis can lead to vascular changes that cause clubbing of the nails over time. Therefore, individuals with chronic bronchitis may also exhibit clubbed nails as a consequence of chronic tissue hypoxia.
Correct Answer is A
Explanation
Choice A Reason:
Standing directly in front of the client and ask about any hearing loss is appropriate because the client's behavior of ignoring questions from the nurse and speaking loudly to her son suggests a potential hearing impairment. Standing directly in front of the client allows for better visibility of facial expressions and lip movements, which can aid in communication for individuals with hearing loss. Asking about any hearing loss helps the nurse gather important information to adapt communication strategies effectively.
Choice B Reason:
Obtaining a tuning fork to complete Rinne and Weber tuning fork tests involves conducting hearing tests using a tuning fork to assess for conductive or sensorineural hearing loss. While these tests are valuable for diagnosing hearing impairments, they are typically performed after obtaining a thorough history and initial assessment, including asking about any hearing loss. Therefore, this option is not the first action to take when communication difficulties are observed.
Choice C Reason:
Beginning to orient the client to her surroundings in the hospital room involves providing orientation to the client about her surroundings, which is important for promoting comfort and reducing anxiety, especially in a new environment like a hospital room. However, addressing potential hearing loss is the priority when the client's behavior suggests difficulty in communication. Once hearing impairment is ruled out or addressed, orientation to the surroundings can be initiated.
Choice D Reason:
Performing a mental status exam to assess the client's thought processes involves assessing the client's cognitive function and thought processes, which is important for understanding the client's overall mental status. While assessing mental status is an essential aspect of comprehensive nursing assessment, it may not directly address the observed communication difficulties related to potential hearing impairment. Therefore, addressing potential hearing loss should be the first action to ensure effective communication before proceeding with a mental status exam.
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