A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which adventitious breath sounds?
Wheezes
Crackles
Rhonchi
Stridor
The Correct Answer is A
A. Wheezes are continuous high-pitched sounds that occur during expiration (or sometimes inspiration) and are common in conditions like asthma due to narrowed airways.
B. Crackles are discontinuous sounds often described as popping or crackling and are not typically high-pitched.
C. Rhonchi are low-pitched, snoring-like sounds caused by the obstruction of larger airways and are not characterized as high-pitched.
D. Stridor is a high-pitched sound usually associated with upper airway obstruction and is not typically heard with asthma.
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Correct Answer is D
Explanation
A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.
B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.
C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.
D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.
Correct Answer is ["A","C","D"]
Explanation
A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.
B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.
C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.
D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.
E. Religion: This does not relate to the clinical findings associated with pneumonia.
F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.
G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.