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 A
Explanation
A. The bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.
B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.
C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.
D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.
Correct Answer is A
Explanation
A. Cranial nerve VII (facial nerve) is not primarily responsible for hearing; however, it does have some sensory function in the ear region. The primary cranial nerve responsible for hearing is cranial nerve VIII (vestibulocochlear), which is not listed among the options.
B. Cranial nerve X (vagus nerve) is primarily involved in autonomic functions and does not directly relate to hearing.
C. Cranial nerve I (olfactory nerve) is responsible for the sense of smell.
D. Cranial nerve II (optic nerve) is responsible for vision.