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

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Use of accessory muscles

Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.

B. Nail bed greater than 160 degrees

Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.

C. Circumoral cyanosis

Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.

D. Pursed lip breathing

Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.

E. Anteroposterior-to-transverse diameter of 1:1

Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.

A. Aorta-Right atrium-right ventricle-pulmonary vein-lungs- pulmonary artery left atrium-left ventricle B. vena cava-right atrium-right ventricle-pulmonary vein-lungs- pulmonary artery-left atrium-left ventricle C. vena cava→ right atrium-right ventricle-pulmonary artery-lungs- pulmonary vein-left atrium-left ventricle D. Aorta-right atrium-right ventricle-lungs-pulmonary vein-left atrium-left ventricle- vena cava

Correct Answer is C

Explanation

In this sequence:

Vena cava brings deoxygenated blood from the body into the right atrium.

Blood flows from the right atrium to the right ventricle through the tricuspid valve.

The right ventricle pumps blood into the pulmonary artery to the lungs.

In the lungs, blood is oxygenated and returns to the heart via the pulmonary veins into the left atrium.

From the left atrium, blood moves to the left ventricle through the bicuspid (mitral) valve.

The left ventricle then pumps oxygenated blood into the body through the aorta.

This sequence represents the systemic and pulmonary circulation of the heart.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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