A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear?
Popping sounds
Loud, gating sounds
Snoring sounds
Squeaky, musical sounds
The Correct Answer is B
Rationale:
A. Popping sounds, also known as crackles, are typically associated with fluid in the alveoli, often seen in conditions like pneumonia or heart failure, not pleurisy.
B. Loud, grating sounds, known as pleural friction rub, are characteristic of pleurisy. This sound is produced by the inflamed pleural surfaces rubbing together during respiration.
C. Snoring sounds, or rhonchi, are usually heard in conditions involving airway obstruction by mucus, such as bronchitis, rather than pleurisy.
D. Squeaky, musical sounds, or wheezing, are associated with airway narrowing, such as in asthma or chronic obstructive pulmonary disease (COPD), and are not typically heard in pleurisy.
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Correct Answer is B
Explanation
Rationale:
A. Drowsiness is not typically associated with thyrotoxicosis; rather, clients are more likely to experience restlessness or insomnia.
B. Heat intolerance is a common symptom of thyrotoxicosis, reflecting the increased metabolic rate associated with excessive thyroid hormone levels.
C. Bradycardia is associated with hypothyroidism, not thyrotoxicosis. In thyrotoxicosis, tachycardia or palpitations are more likely.
D. Dry skin is a symptom of hypothyroidism, whereas in thyrotoxicosis, the skin may become warm, moist, and flushed.
Correct Answer is ["B","E","F"]
Explanation
Rationale:
A. The vital signs are stable and within normal limits. The slight drop in blood pressure post-dialysis is expected and not immediately concerning.
B. The client's weight decreased from 90 kg (198 lb) to 86.4 kg (190 lb) after dialysis. While weight loss is expected due to fluid removal during dialysis, this significant decrease (3.6 kg or approximately 8 lb) may need closer monitoring to ensure the client is not becoming dehydrated or losing more fluid than is safe.
C. The blood glucose levels are within an acceptable range for a client with type 2 diabetes mellitus. The slight decrease from 134 mg/dL to 75 mg/dL is not unusual given the time between measurements and the client's food intake.
D. The presence of a bruit and thrill at the AV fistula site indicates that it is functioning correctly, which is an expected finding.
E. The presence of crackles in the left lower lobe and an unproductive cough on the morning of Day 2 is concerning. These symptoms could indicate fluid overload or early signs of pulmonary edema, which require further evaluation and possible intervention.
F. The AV fistula site is noted to be ecchymotic and warm, with a bruit and thrill still present. While a bruit and thrill are expected findings, the ecchymosis and warmth could indicate a developing infection or trauma at the site, which necessitates further follow-up to prevent complications.