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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?

A.

Wheezes

B.

Crackles

C.

Rhonchi

D.

Stridor

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

A. Providing a safe and comfortable environment and applying critical thinking involves both objective and subjective data collection, not just one type.

B. While family members can contribute to patient care, the professional responsibilities of providing a safe environment and critical thinking in assessments fall to trained healthcare providers.

C. This process encompasses both subjective and objective data, as critical thinking requires integrating multiple types of information.

D. The actions described are essential professional responsibilities of trained healthcare providers, who must ensure a safe environment, apply critical thinking, and identify patient cues effectively.

Correct Answer is A

Explanation

A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.


B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.


C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.


D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.

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