After auscultating which adventitious breath sound should the nurse have the patient cough and then auscultate again?

Rhonchi.

Wheeze.

Crackles.

Stridor.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.

Choice B rationale

Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.

Choice C rationale

Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.

Choice D rationale

Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .

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Correct Answer is A

Explanation

Choice A rationale

The Romberg test evaluates equilibrium by having the client stand with feet together and eyes closed, observing for swaying or imbalance. It assesses the function of the vestibular system, proprioception, and cerebellar function, making it the most appropriate test for assessing dizziness and equilibrium.

Choice B rationale

The Weber test involves placing a tuning fork on the forehead to evaluate sound lateralization. It assesses hearing loss but not equilibrium, making it less suitable for dizziness assessment.

Choice C rationale

The Rinne test compares air and bone conduction of sound using a tuning fork. While useful for diagnosing conductive hearing loss, it does not assess equilibrium, making it inappropriate for evaluating dizziness.

Choice D rationale

The cover test evaluates eye alignment and muscle function by having the client cover one eye and observe the uncovered eye for movement. It assesses ocular motility but not equilibrium, making it unsuitable for dizziness assessment.

A. Age 19 to 30 years. B. Dark hair. C. Female gender. D. History of repeated sunburn.

Correct Answer is D

Explanation

Choice A rationale

While individuals aged 19 to 30 years are generally at a lower risk for malignant melanoma compared to older adults, melanoma can still occur at any age, especially with certain risk factors. However, age alone does not significantly increase the risk of developing malignant melanoma without additional risk factors.

Choice B rationale

Hair color has minimal impact on the risk of developing malignant melanoma. Although individuals with fair skin and light hair have a higher risk of sunburn and subsequent melanoma, having dark hair does not significantly reduce the risk compared to other factors.

Choice C rationale

Female gender does not inherently increase the risk of developing malignant melanoma. Both males and females are at risk, although certain lifestyle factors and behaviors, such as sun exposure, can influence individual risk levels regardless of gender.

Choice D rationale

A history of repeated sunburn significantly increases the risk of developing malignant melanoma. Ultraviolet (UV) radiation from sunburns causes DNA damage in skin cells, leading to mutations that can result in melanoma. Repeated sunburns exacerbate this risk, making it a critical factor in melanoma development.

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After auscultating which adventitious breath sound should the nurse have the patient cough and then auscultate again?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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