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 A
Explanation
Rationale:
A. Hyperparathyroidism often leads to elevated levels of calcium in the blood, which can result in joint and bone pain due to the excessive breakdown of bone tissue (osteoporosis).
B. Tremors are not typically associated with hyperparathyroidism; they are more commonly linked to conditions like hyperthyroidism or neurological disorders.
C. Swelling in the legs is more commonly associated with conditions like heart failure or venous insufficiency, not hyperparathyroidism.
D. Diarrhea is not a common symptom of hyperparathyroidism; this condition is more likely to cause constipation due to hypercalcemia.
Correct Answer is C
Explanation
Rationale:
A. Assisting the client to the bathroom might be helpful, but it is not the first action the nurse should take since the client hasn't voided for an extended period.
B. Increasing fluids may be beneficial but does not address the immediate concern of whether there is a problem with urinary retention.
C. Performing a bladder scan is the first action to determine if there is urine retention in the bladder. This information is crucial before deciding on further interventions, such as catheterization.
D. Inserting a straight catheter may be necessary if significant urinary retention is confirmed, but it should not be the first action without knowing the bladder's status.