The nurse is listening to the breath sounds of young adult client with severe asthma. The nurse recognizes that air passing through narrowed bronchioles would produce which of these adventitious sounds?
Wheezes
Whispered pectoriloquy
Bronchial sounds
Bronchophony
The Correct Answer is A
A. Wheezes:
Wheezes are continuous, high-pitched, whistling lung sounds that are heard especially during expiration and sometimes during inspiration. They are caused by the rapid movement of air through narrowed or constricted airways, which is common in conditions like asthma. Wheezing is a characteristic adventitious sound associated with asthma and other obstructive respiratory disorders.
B. Whispered Pectoriloquy:
Whispered Pectoriloquy is an increased loudness of whispering noted during auscultation with a stethoscope on the lung fields. This phenomenon occurs when sound is transmitted clearly through consolidated or compressed lung tissue, making whispered sounds more distinct. It is a sign of lung consolidation, often seen in conditions like pneumonia.
C. Bronchial Sounds:
Bronchial sounds are harsh, high-pitched sounds heard over the trachea and the large bronchi. These sounds are normally heard during expiration. If they are heard over peripheral lung areas, it can indicate consolidation or compression of lung tissue, possibly due to pneumonia or tumor.
D. Bronchophony:
Bronchophony is a phenomenon in which spoken sounds are heard more clearly and distinctly through the stethoscope on auscultation of the lungs. Normally, sounds are muffled during auscultation. Increased clarity of spoken sounds can indicate lung consolidation, similar to whispered pectoriloquy, and is often associated with conditions like pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Discuss that a light will be directed at the neck to observe for pulsations of the artery:
This choice is incorrect. Directing light at the neck is not a standard method for assessing carotid artery pulsations. The carotid artery is usually assessed by palpation to feel the pulse rather than visual observation.
B. Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates:
This choice is incorrect. Auscultation is typically not used to assess carotid artery pulsations. Palpation (feeling the pulse) is the primary method used for this assessment.
C. Demonstrate that both arteries will be palpated simultaneously to compare amplitude:
This choice is correct. Palpating both carotid arteries simultaneously allows the nurse to compare the amplitude (strength) of the pulses. This comparison helps in assessing the symmetry of the pulses and ensures there are no significant differences between the two sides, which could indicate vascular abnormalities.
D. Show the client the diaphragm of the stethoscope that will be placed on the neck:
This choice is incorrect. The diaphragm of the stethoscope is not typically used for palpating pulses. Palpation involves using the fingertips to feel the pulse and assess its strength and regularity.
Correct Answer is D
Explanation
A. A shiny, pearly white color tympanic membrane: This is a normal finding. A healthy tympanic membrane often appears shiny and pearly white.
B. The presence of cerumen: This is a normal finding. Cerumen, or earwax, is a natural substance that helps protect the ear canal.
C. The presence of a cone of light: This is a normal finding. The cone of light is a reflection of the otoscope light on the tympanic membrane and is a normal variation.
D. A yellow or amber color to the tympanic membrane: This is considered an abnormal finding. A yellow or amber coloration of the tympanic membrane can indicate the presence of fluid or infection behind the eardrum, which may be a sign of otitis media or other ear conditions.
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