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 B
Explanation
A. Assessing the pedal pulses does not provide relevant information about the irregularity of the radial pulse.
B. Assessing the apical pulse for a full minute is appropriate in this situation, as it provides a more accurate measurement of the heart rate and rhythm, especially when the radial pulse is irregular.
C. Assessing the popliteal pulses with a Doppler device is not necessary and does not directly address the irregular radial pulse.
D. While a pulse oximeter can provide information about oxygen saturation, it does not assess heart rate or rhythm.
Correct Answer is A
Explanation
A. Having the child bend at the waist allows the nurse to observe the spine for any abnormal curvature indicative of scoliosis, such as uneven shoulders or a rib hump.
B. Measuring the distance between the knees and the ankles is not a technique used to screen for scoliosis; it is more related to assessing leg length discrepancies.
C. Measuring the length of each leg does not assess for scoliosis but is more relevant for evaluating leg length inequalities.
D. Asking the child to walk across the room is useful for assessing gait and balance but does not directly assess for scoliosis.