What is the term used for a high pitched musical sound in clients during a respiratory assessment?

ANS: 3
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function
Chapter page reference: 448-449
Heading: Assessment/Percussion/Table 23.1 - Percussion Sounds
Integrated Processes: Communication and Documentation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Easy

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1 Dull sounds are medium pitched, thud sounds observed when percussing over the liver, heart, kidney, or diaphragm. Dull sounds may be assessed in patient with pneumonia, atelectasis, or a lung mass.
2 Tympany is a drum-like, loud, empty quality heard over a gas-filled stomach or intestine.
3 Low-pitched sounds heard over normal lungs during percussion indicate resonance.
4 Hyperresonance is a loud, lower-pitched sound heard when percussing hyperinflated lungs, which can occur in patients who are experiencing an acute asthma exacerbation.

PTS: 1 CON: Assessment

ANS: 1
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 5. Explaining nursing considerations for diagnostic studies relevant to respiratory function
Chapter page reference: 452
Heading: Diagnostic Testing/Capnography and Capnometry
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Assessment
Difficulty: Moderate
Feedback
1 Increases in end-tidal CO2 levels may be from an increase in cellular metabolism, resulting in an increase in CO2 production or hyperventilation that causes an increase in the excretion of CO2 from the lungs. Disease processes that result in increased CO2 levels are hyperthermia, trauma, burns, or sepsis.
2 Decreases in the end-tidal CO2 levels result from inadequate ventilation, respiration, or pulmonary perfusion. Disease processes that result in lower end-tidal CO2 levels are hypothermia, sedation, pulmonary embolism, hypoperfusion of the pulmonary system, endotracheal tube placement in the esophagus, systemic hypotension, and cardiac arrest.
3 Decreases in the end-tidal CO2 levels result from inadequate ventilation, respiration, or pulmonary perfusion. Disease processes that result in lower end-tidal CO2 levels are hypothermia, sedation, pulmonary embolism, hypoperfusion of the pulmonary system, endotracheal tube placement in the esophagus, systemic hypotension, and cardiac arrest.
4 Decreases in the end-tidal CO2 levels result from inadequate ventilation, respiration, or pulmonary perfusion. Disease processes that result in lower end-tidal CO2 levels are hypothermia, sedation, pulmonary embolism, hypoperfusion of the pulmonary system, endotracheal tube placement in the esophagus, systemic hypotension, and cardiac arrest.

PTS: 1 CON: Assessment

ANS: 3, 4, 5
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1 This is incorrect. Patients with asthma typically develop wheezing that is described as a squeaky musical instrument caused by bronchoconstriction and inflammation.
2 This is incorrect. Patients with bronchitis may have fine rhonchi (fine rales), described as the sound of rubbing hair follicles together caused by inflation of previously deflated lung tissue, or rhonchi, described as snoring sounds caused by obstruction in the airways.
3 This is correct. Coarse crackles (coarse rales), described as a popping/coarse sound caused by fluid or secretions in lower airways, may be observed in patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and congestive heart failure.
4 This is correct. Coarse crackles (coarse rales), described as a popping/coarse sound caused by fluid or secretions in lower airways, may be observed in patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and congestive heart failure.
5 This is correct. Coarse crackles (coarse rales), described as a popping/coarse sound caused by fluid or secretions in lower airways, may be observed in patients with COPD, sputum in the airways, pneumonia, pulmonary edema, and congestive heart failure.

PTS: 1 CON: Assessment

ANS: 1, 3, 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1 This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may have fine crackles (fine rales) that are described as the sound of rubbing hair follicles together caused by inflation of previously deflated lung tissue.
2 This is incorrect. Patients with pulmonary edema usually manifest with coarse crackles as a result of fluid in the lower airways.
3 This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may have fine crackles (fine rales) that are described as the sound of rubbing hair follicles together caused by inflation of previously deflated lung tissue.
4 This is correct. Patients with bronchitis, COPD, fibrosis, and pneumonia may have fine crackles (fine rales) that are described as the sound of rubbing hair follicles together caused by inflation of previously deflated lung tissue.
5 This is incorrect. Patients with asthma typically develop wheezing that is described as a squeaky musical instrument caused by bronchoconstriction and inflammation.

PTS: 1 CON: Assessment

ANS: 3, 4, 5
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1 This is incorrect. Patients with asthma typically develop wheezing that is described as a squeaky musical instrument caused by bronchoconstriction and inflammation.
2 This is incorrect. Patients with COPD typically have fine or coarse crackles on auscultation.
3 This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body obstruction, masses or malignancies in the lungs, and pneumonia.
4 This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body obstruction, masses or malignancies in the lungs, and pneumonia.
5 This is correct. Rhonchi are auscultated in patients with bronchitis, foreign body obstruction, masses or malignancies in the lungs, and pneumonia.

PTS: 1 CON: Assessment

ANS: 1, 3, 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 3. Describing the procedure for completing a history and physical assessment of respiratory function
Chapter page reference: 448-450
Heading: Assessment/Auscultation/Table 23.4 - Abnormal or Adventitious Lung Sounds
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Assessment
Difficulty: Moderate
Feedback
1 This is correct. Stridor, described as a high-pitched sound during inspiration caused by airway obstruction of the throat or upper airway or spasm of the airway, may be auscultated in patients with allergic reactions, epiglottis, and laryngitis.
2 This is incorrect. Patients with COPD typically have fine or coarse crackles on auscultation.
3 This is correct. Stridor, described as a high-pitched sound during inspiration caused by airway obstruction of the throat or upper airway or spasm of the airway, may be auscultated in patients with allergic reactions, epiglottis, and laryngitis.
4 This is correct. Stridor, described as a high-pitched sound during inspiration caused by airway obstruction of the throat or upper airway or spasm of the airway, may be auscultated in patients with allergic reactions, epiglottis, and laryngitis.
5 This is incorrect. Pleural friction rubs are auscultated in patients with pleurisy. These sounds, described as grating or squeaking, are caused by inflammation in the pleural space.

PTS: 1 CON: Assessment

ANS: 1, 2, 4
Chapter number and title: 23, Assessment of Respiratory Function
Chapter learning objective: 4. Correlating relevant diagnostic examinations to respiratory function
Chapter page reference: 448
Heading: Auscultation/Safety Alert: Dyspnea
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1 This is correct. Patients who are reporting dyspnea demonstrate accessory muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and should be referred for immediate medical intervention.
2 This is correct. Patients who are reporting dyspnea demonstrate accessory muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and should be referred for immediate medical intervention.
3 This is incorrect. Patients with dyspnea who have worsening of respiratory status will manifest tachypnea, not hyperventilation.
4 This is correct. Patients who are reporting dyspnea demonstrate accessory muscle use, adventitious breath sounds, cyanosis, retractions, and tachypnea and should be referred for immediate medical intervention.
5 This is incorrect. Vesicular are normal breath sounds.

PTS: 1 CON: Oxygenation

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