The nurse is palpating a client's anterior chest wall and notices a course, crackling sensation over the skin surface. Which of the following should the nurse suspect from her findings?
Friction rub
Tactile fremitus
Crepitus
Adventitious sounds
The Correct Answer is C
A. Friction rub:
A friction rub is a grating or rubbing sound or sensation heard or felt during auscultation or palpation. It occurs when inflamed pleural or pericardial surfaces rub against each other during breathing or heartbeats, respectively.
B. Tactile fremitus:
Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks. It is assessed by placing hands on the patient's back while the patient speaks certain words. Increased tactile fremitus can occur in conditions with lung consolidation, such as pneumonia.
C. Crepitus:
Crepitus is a crackling or grating sensation felt under the skin or heard when the ends of a broken bone rub against each other. It can also occur when air leaks into subcutaneous tissue, leading to a crackling sensation upon palpation.
D. Adventitious sounds:
Adventitious sounds refer to abnormal lung sounds heard during auscultation. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. Adventitious sounds can indicate various respiratory conditions, such as pneumonia, bronchitis, or asthma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Indicates turbulent blood flow through a valve:
This statement is correct. A heart murmur is an abnormal sound during the heartbeat cycle, often indicating turbulent blood flow through a valve. Murmurs can result from various factors such as valve disorders, structural abnormalities, or other heart conditions.
B. Is an extra sound due to blood entering an inflexible chamber:
This statement is not accurate. Heart murmurs are primarily associated with turbulent blood flow rather than an extra sound related to an inflexible chamber.
C. Means that there is some inflammation around the heart:
This statement is incorrect. Heart murmurs are not specifically related to inflammation around the heart. They are primarily caused by issues with blood flow through the heart valves.
D. Is a high-pitched sound due to a narrow valve:
This statement is a bit oversimplified. While murmurs can sometimes be associated with narrow valves (stenosis), they can also result from various other valve abnormalities or conditions, and not all murmurs are high-pitched. The pitch and characteristics of a murmur can provide clues about its cause, but they are not the sole indicators.
Correct Answer is C
Explanation
A. Friction rub:
A friction rub is a grating or rubbing sound or sensation heard or felt during auscultation or palpation. It occurs when inflamed pleural or pericardial surfaces rub against each other during breathing or heartbeats, respectively.
B. Tactile fremitus:
Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks. It is assessed by placing hands on the patient's back while the patient speaks certain words. Increased tactile fremitus can occur in conditions with lung consolidation, such as pneumonia.
C. Crepitus:
Crepitus is a crackling or grating sensation felt under the skin or heard when the ends of a broken bone rub against each other. It can also occur when air leaks into subcutaneous tissue, leading to a crackling sensation upon palpation.
D. Adventitious sounds:
Adventitious sounds refer to abnormal lung sounds heard during auscultation. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. Adventitious sounds can indicate various respiratory conditions, such as pneumonia, bronchitis, or asthma.
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