The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided).

Audio: [Wheezing sound]

Wheeze

Rhonchi

Stridor.

Fine crackles.

Answer and Explanation

The Correct Answer is A

Based on the provided audio clip, the sound heard is a high-pitched, continuous, musical sound. This sound is characteristic of wheezing, which is caused by the narrowing of the airways due to inﬂammation, bronchoconstriction, or the presence of mucus. Wheezing is commonly associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.

Let's evaluate the other options:

b) Rhonchi: Rhonchi are low-pitched, coarse, ratling sounds that typically indicate the presence of mucus or ﬂuid in the larger airways. Rhonchi are often heard in conditions such as pneumonia or bronchitis, but they are diﬀerent from the high-pitched wheezing sound heard in the audio clip.

c) Stridor: Stridor is a high-pitched, harsh, and crowing sound that is heard during inspiration. It is often associated with upper airway obstruction, such as in cases of croup, epiglottitis, or a foreign body obstruction. The sound in the audio clip does not match the characteristics of stridor.

d) Fine crackles: Fine crackles are discontinuous, high-pitched, and brief sounds that are typically heard during inspiration. They are often described as "velcro-like" or "rice crispies" and are associated with conditions such as pulmonary fibrosis or congestive heart failure. The sound in the audio clip does not resemble fine crackles.

In summary, the sound in the provided audio clip is best described as wheezing, characterized by a high- pitched, continuous, musical sound. Therefore, the practical nurse (PN) should document this sound as "wheeze."

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Correct Answer is B

Explanation

Choice A rationale:

Reducing the client's interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and worsen the client's agitation and delusions. It does not address the client's emotional distress.

Choice B rationale:

Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client's focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.

Choice C rationale:

Awakening the client earlier for daily morning care may further disrupt the client's sleep patterns and worsen agitation. It does not address the underlying issue of delusional thoughts and the client's emotional distress.

Choice D rationale:

Clarifying reality with the client about delusional thoughts can be counterproductive in dementia care. The client's cognitive impairment may make it challenging for them to understand or accept the clarification, leading to increased frustration and agitation. It is essential to use a more empathetic and therapeutic approach.

A. Domestic violence assistance. B. Blood pressure screening. C. Immunizations that are available. D. Outreach for support group information.

Correct Answer is C

Explanation

Choice A rationale:

Domestic violence assistance is an important topic, but it falls under secondary and tertiary prevention rather than primary disease prevention, which is the focus of this community outreach program. Primary prevention aims to prevent the disease from occurring in the first place, while domestic violence assistance addresses an existing issue.

Choice B rationale:

Blood pressure screening is valuable for early detection of hypertension, but it also falls under secondary prevention. Primary prevention focuses on preventing the onset of diseases through measures such as immunizations, health education, and lifestyle modifications.

Choice D rationale:

Outreach for support group information is essential for clients with chronic conditions or specific needs. However, it is not primarily related to preventing diseases at the population level, which is the primary goal of this community outreach program. This topic may be more relevant to secondary and tertiary prevention efforts.

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The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound]

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The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided).

Audio: [Wheezing sound]