Author Question: A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that ... (Read 101 times)

Jipu 123 · **on:** Jul 22, 2018

A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that are described as grating or leathery. What type of adventitious sounds are these?

A) Crackles
B) A rub
C) A wheeze
D) Gurgles

Question 2

A home care nurse is caring for a middle-aged client with fecal incontinence. The client states that her friends recently came to visit her, but the client was reluctant to meet them because of her problem.

Which of the following nursing diagnoses should the nurse identify? A) Risk for infection
B) Situational low self-esteem
C) Diarrhea
D) Spiritual distress

amcvicar · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Feedback:
Rubs are grating or leathery sounds caused by two dry pleural surfaces moving over each other. Crackles are intermittent, high-pitched, popping sounds, which are heard in distant areas of the lungs during inspiration. Wheezes are whistling or squeaking sounds caused by air moving through a narrow passage, which can be heard throughout the chest during expiration or inspiration. Gurgles are low-pitched, continuous, bubbling adventitious sounds, which are prominent during expiration, and are heard in larger airways.

Answer to Question 2

B
Feedback:
The nurse should diagnose the client with situational low self-esteem since the client's fecal incontinence has impacted her social life and identity. Diarrhea does not necessarily accompany fecal incontinence. The risk of infection is significant, but not paramount. The client's reluctance is not necessarily associated with spiritual distress.