The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)
As the patient says a long "ee-ee ee" sound, the examiner hears a long "aaaaaa" sound.
When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said
As the patient says a long "ee-ee-ee sound, the examiner also hears a long "ee-ee-ee" sound.
As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninetynine."
Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice
Correct Answer : C,D
A. As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound. - This indicates a possible consolidation in the lungs, which is abnormal.
B. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. - This suggests abnormal voice transmission and could indicate lung consolidation or other issues.
C. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. - This is normal, indicating clear and symmetrical transmission of voice sounds.
D. As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." - This is also normal, as it indicates normal transmission of sound and no lung consolidation.
E. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. - This is normal for whispered voice sounds and is not a sign of abnormal lung findings.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F"]
Explanation
A. Skin turgor refers to the elasticity of the skin, which can be affected by various conditions, including malignancy. The nurse should assess for any skin changes near the lump to identify any unusual signs.
B. The nurse should document the precise location of the mass, noting whether it is near the nipple or in another quadrant of the breast. This will help with future imaging and assessment.
C. While the history is important, it does not fall under objective findings that the nurse would document during the physical exam.
D. This is part of the patient’s history, not a direct observation during the physical exam, so it is not included in the documentation of objective findings of the breast mass.
E. Orientation refers to the patient’s mental status and does not relate to the characteristics of the breast mass.
F. The nurse should note the consistency of the mass (e.g., hard, firm, or soft). A firm, non-tender mass is often concerning for malignancy and should be documented.
Correct Answer is A
Explanation
A. This is the most appropriate time to perform a testicular self-examination because the scrotum is relaxed and easier to examine after warm water exposure.
B. The testicle is egg-shaped and movable, but it should not feel lumpy. Lumps or abnormal findings should be reported to a healthcare provider.
C. While this advice is helpful, it does not answer the question of when or how to perform the
examination.
D. A monthly exam is generally recommended, not weekly, to detect early signs of testicular cancer.
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