The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

Choice A Reason:
The Review of Systems (ROS) is a systematic approach for collecting the patient's self-reported data on all body systems. It is not typically where the narrative of symptoms is documented. Instead, the ROS is used to uncover symptoms the patient may not have mentioned during the initial recounting of their history.

Choice B Reason:
The Chief Complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, or other factors that are the reason for the encounter, usually stated in the patient's words¹. While it does include the symptom prompting the visit, it is not the section where a detailed narrative or description of symptoms is provided.

Choice C Reason:
The History of Present Illness (HPI) is indeed where the detailed narrative of the patient's symptoms is documented. It includes the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date. The HPI tells the story of the patient's chief complaint and provides context for the clinical reasoning process.

Choice D Reason:
The Past Medical History (PMH) includes information about the patient's past experiences with illnesses, operations, injuries, and treatments. It does not contain the current symptoms' narrative but rather the patient's health status before the present illness or concern.

Choice A reason:

Reddened intact skin is typically associated with a stage 1 pressure ulcer, where the skin is not yet broken but shows signs of redness. This stage indicates that the skin is under pressure and may be at risk for further breakdown if the pressure is not relieved.

Choice B reason:

A stage 3 pressure ulcer involves full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer presents as a deep crater, and there may be slough or eschar present. It is important to manage these ulcers carefully to prevent further deterioration and complications such as infection.

Choice C reason:

Skin loss involving up to the dermis layer is characteristic of a stage 2 pressure ulcer. In this stage, the epidermis and part of the dermis are lost, creating a shallow open wound or blister. This stage is less severe than stage 3 and requires different management strategies to promote healing and prevent progression.

Choice D reason:

Exposed bone is indicative of a stage 4 pressure ulcer, which is the most severe stage. It involves full-thickness skin loss with extensive destruction, possibly including muscle, tendon, or bone exposure. These ulcers are at high risk for serious infections, including osteomyelitis, and require aggressive medical and surgical intervention to heal.