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 ["B","C","D","E"]

Explanation

A. Age: While age itself is not modifiable, it is included in the list because aging increases the risk of developing cardiovascular disease. However, individuals cannot change their age, so it is not a modifiable risk factor.

B. Smoking: Smoking is a significant risk factor for cardiovascular disease. It damages the heart and blood vessels and can lead to atherosclerosis (narrowing and hardening of the arteries), which can result in heart attacks and strokes.

C. Hypertension: High blood pressure is a leading cause of cardiovascular disease. It can damage the arteries over time, making them more susceptible to atherosclerosis.

D. Diabetes: Diabetes, especially if poorly controlled, increases the risk of cardiovascular disease. High blood sugar levels can damage the blood vessels and the heart.

E. High cholesterol: Elevated levels of cholesterol, especially low-density lipoprotein (LDL) cholesterol, can lead to the buildup of plaque in the arteries, increasing the risk of atherosclerosis and cardiovascular events.

A. Increased temperature B. Increase hematocrit C. Blood pressure 180/100 D. Respiratory rate 32 E. Heart rate 120bpm

Correct Answer is ["C","D"]

Explanation

A. Increased temperature: Fluid overload typically doesn't cause an increased temperature. Infections or other inflammatory processes are more likely causes of elevated body temperature.

B. Increased hematocrit: Fluid overload usually results in dilution of blood components, leading to a decreased hematocrit (lower concentration of red blood cells in the blood). An increased hematocrit is not a typical finding in fluid overload.

C. Blood pressure 180/100: Elevated blood pressure can be associated with fluid overload, especially if the overload is chronic. This is a correct assessment finding that requires intervention and monitoring.

D. Respiratory rate 32: An increased respiratory rate can be a sign of respiratory distress, which may occur in severe cases of fluid overload, especially if it leads to pulmonary edema. This is a correct assessment finding that requires intervention and further evaluation.

E. Heart rate 120 bpm: An increased heart rate can be a compensatory mechanism in response to fluid overload, especially if the heart is trying to maintain cardiac output. However, this heart rate alone is not specific enough to confirm fluid overload. Other signs and symptoms, such as edema, increased blood pressure, and respiratory distress, are more indicative of fluid overload.

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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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Explanation

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