During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

Increased tactile fremitus and dull percussion tones.

Muffled voice sounds and symmetric tactile fremitus.

Adventitious sounds and limited chest expansion.

Absent voice sounds and hyper resonant percussion tones.

Answer and Explanation

The Correct Answer is B

A.   Increased tactile fremitus and dull percussion tones would suggest consolidation or pathology, which is not normal.
B.   Muffled voice sounds and symmetric tactile fremitus are normal findings in healthy lung tissue.
C.   Adventitious sounds and limited chest expansion would indicate pathology such as pneumonia or other lung diseases.
D.   Absent voice sounds and hyper resonant percussion tones would be indicative of a pneumothorax or emphysema, not normal lung findings.

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Correct Answer is C

Explanation

A. Xerostomia (dry mouth) is common in some conditions but not typically associated with a stroke.
B. Rhinorrhea (runny nose) is not a typical finding related to stroke.
C. Dysphagia (difficulty swallowing) is a common issue for patients after a stroke, especially if the stroke affects the areas of the brain responsible for swallowing.
D. Epistaxis (nosebleed) is not a direct consequence of a stroke. The nurse should be more concerned with symptoms related to swallowing, speech, and motor function, such as dysphagia.

A. Peripheral vascular disease B. Fluid and electrolyte disturbances C. Heart failure D. Atrial-septal defect

Correct Answer is C

Explanation

A. Peripheral vascular disease involves issues with blood flow to the extremities but does not typically present with jugular vein distension or a gallop heart sound.
B. Fluid and electrolyte disturbances may affect heart rhythm and fluid balance but are less likely to present with these specific findings.
C. Heart failure is the most likely cause, as jugular vein distension and a third heart sound (S3 gallop) are common signs of heart failure, particularly when the heart cannot effectively pump blood.
D. Atrial-septal defect may cause heart murmurs or irregular rhythms but is not typically associated with jugular vein distension or an S3 gallop.

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During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

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Naxlex Comprehensive Predictor Exams

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

Correct Answer is C

Explanation

During a cardiac assessment of a client you observed jugular vein distension, and auscultated $3 gallop heart sound. These findings most likely suggest which of the following conditions?

Correct Answer is C

Explanation

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During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: