A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say "ee," and if the sound is heard as "ay," this is known as:

Bronchovesicular sound

Bronchophony

Normal voice resonance

Egophony

Answer and Explanation

The Correct Answer is D

Choice a reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. Bronchovesicular sounds do not involve the change of vowel sounds during auscultation.

Choice b reason:
Bronchophony is the term used when the voice sounds are more clear and louder over the chest wall, usually indicating lung consolidation. However, it does not specifically refer to the change of vowel sounds from "ee" to "ay."

Choice c reason:
Normal voice resonance is when voice sounds heard through auscultation are muffled and indistinct. It does not involve a clear change in vowel sounds, which is what occurs with egophony.

Choice d reason:
Egophony is characterized by the change of the "ee" vowel sound to a nasal "ay" or "a" sound when auscultating the lungs. This phenomenon typically suggests lung consolidation, as might be seen with pneumonia.

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Correct Answer is A

Explanation

Choice a reason :
Referring the client for medical follow-up is the most appropriate action. Acanthosis Nigricans is often associated with insulin resistance and is a risk factor for diabetes mellitus. The client's symptoms of fatigue, thirst, and frequent urination are classic signs of diabetes. Therefore, a comprehensive medical evaluation is necessary to rule out diabetes or other underlying conditions that could be causing these symptoms.
Choice b reason
While Acanthosis Nigricans can sometimes be associated with malignancy, it is more commonly linked to insulin resistance and diabetes. The client's presenting symptoms are not typical of cancer but are indicative of diabetes. Therefore, while a family history of cancer is relevant to the client's overall health, it is not the immediate concern based on the current presentation.
Choice c reason
Documenting findings is an essential part of the nursing process; however, the presence of Acanthosis Nigricans, especially when coupled with symptoms of fatigue, thirst, and frequent urination, should not be considered benign without further investigation. These findings warrant further assessment to determine the underlying cause.
Choice d reason
Performing a random blood sugar test could be a part of the initial assessment; however, it should not replace a referral for a comprehensive medical evaluation. A random blood sugar test alone may not be sufficient to diagnose diabetes or determine the cause of the client's symptoms. A full medical follow-up will likely include blood sugar testing along with other diagnostic tests.

A. Wear nonslip shoes in the house. B. Use of guns should be supervised by an adult. C. Always use seat belts. D. Avoid risky activities such as snowboarding.

Correct Answer is ["A","B","C","D"]

Explanation

Choice a reason:
Wearing nonslip shoes in the house is a preventive measure against falls, which are a leading cause of traumatic brain injuries (TBIs) in adolescents. Nonslip shoes provide better grip and stability, especially on potentially slippery surfaces like tiles or polished wood, reducing the risk of slips and falls that can lead to head injuries.

Choice b reason:
The supervised use of guns by an adult is critical in preventing accidental shootings, which can result in TBIs. Adolescents may lack the maturity and experience to handle firearms safely, and adult supervision ensures that proper safety protocols are followed, reducing the risk of accidental discharge and potential injury.

Choice c reason:
The use of seat belts is one of the most effective ways to prevent TBIs in the event of a vehicle accident. Seat belts restrain the body and prevent individuals from being thrown around inside or ejected from the vehicle, significantly reducing the likelihood of head trauma.
Choice d reason:
Avoiding risky activities such as snowboarding without proper safety equipment is essential in preventing sports-related TBIs. Snowboarding, like other high-speed sports, carries a risk of falls and collisions, which can cause head injuries. Wearing helmets and other protective gear, and engaging in these activities with caution, can mitigate this risk.

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A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say "ee," and if the sound is heard as "ay," this is known as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae (Acanthosis Nigricans). What would the nurse do next?

Correct Answer is A

Explanation

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

Correct Answer is ["A","B","C","D"]

Explanation

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

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