While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

Rhonchi

Crackles

Bronchovesicular

Tracheal

Answer and Explanation

The Correct Answer is C

Choice a reason:
Rhonchi are coarse, rattling respiratory sounds somewhat like snoring, usually caused by obstruction or secretion in the larger airways. They are not considered normal breath sounds and are typically heard in conditions such as chronic bronchitis.

Choice b reason:
Crackles are the sounds you will hear in a lung field that has fluid in the small airways. These sounds are commonly heard in patients with pneumonia, heart failure, and restrictive pulmonary diseases. They are not normal breath sounds.

Choice c reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. In a healthy individual, these sounds are expected to be heard in the 1st and 2nd intercostal spaces near the sternal body.

Choice d reason:
Tracheal breath sounds are harsh, high-pitched sounds heard when auscultating over the trachea in the neck. They are not normally heard over the intercostal spaces of the chest wall.

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Correct Answer is C

Explanation

Choice A Reason:
Palpitations are typically associated with hyperthyroidism, not hypothyroidism. They occur due to an excess of thyroid hormones, which can overstimulate the heart, leading to increased heart rate and palpitations. In hypothyroidism, the heart rate is usually slower, and palpitations are less common.

Choice B Reason:
Diaphoresis, or excessive sweating, is also more commonly associated with hyperthyroidism. In hypothyroidism, the metabolism is slowed down, which reduces the tendency for increased sweating. Patients with hypothyroidism may actually have less sweating than normal.

Choice C Reason:
Weight gain is a common symptom of hypothyroidism. Due to the decreased metabolic rate caused by low levels of thyroid hormones, the body burns fewer calories, which can lead to weight gain. This is one of the hallmark signs of hypothyroidism and is often one of the first symptoms patients notice.

Choice D Reason:
Exophthalmos, the protrusion of the eyes, is a symptom associated with Graves' disease, a form of hyperthyroidism. It is not a symptom of hypothyroidism. In hypothyroidism, any eye changes are usually related to puffiness or edema around the eyes, not the bulging of the eyes themselves.

A. Peripheral vision. B. External eye structures. C. Distant vision. D. Near vision.

Correct Answer is C

Explanation

Choice A reason:
Peripheral vision is the ability to see objects and movement outside of the direct line of vision. This type of vision is assessed using different methods, such as confrontation visual field testing, where the examiner moves objects into the patient's side vision from different angles. Standing 20 feet away from a chart would not be the appropriate method to assess peripheral vision.
Choice B reason:
The assessment of external eye structures involves examining the physical appearance and condition of the eyelids, sclera, conjunctiva, and surrounding areas. This is typically done at a close range and does not require the patient to stand at a distance from a chart. The nurse would inspect these structures directly, often with the aid of a penlight for better visibility.

Choice C reason:
Distant vision is the ability to see objects far away, and it is what the nurse is preparing to assess when the client is asked to stand 20 feet from a chart. This distance is standard for the Snellen eye chart, which is used to measure visual acuity. The chart has rows of letters that decrease in size, and the patient is asked to read the smallest line of letters they can see clearly. The Snellen chart is the most common method used by eye doctors to measure visual acuity.
Choice D reason:
Near vision is the ability to see objects that are close to the eyes clearly. It is assessed using different charts, such as the Jaeger eye chart, which contains blocks of text in various type sizes. The patient is asked to read the text at a close range, typically around 14 inches, not 20 feet. Therefore, standing 20 feet away from a chart would not be the method to assess near vision.

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While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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