Health Promotion and Maintenance Q 113
Mrs. Chua, a 78-year-old client, is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be:
A. Stridor
B. Crackles
C. Wheezes
D. Friction rubs
Correct Answer: B. Crackles
Left-sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Pulmonary edema may cause crackling sounds in the lungs. People with congestive heart failure (CHF) often have pulmonary edema. CHF occurs when the heart cannot pump blood effectively. This results in a backup of blood, which increases blood pressure and causes fluid to collect in the air sacs in the lungs.
Option A: Stridor may result from lesions involving the central nervous system (CNS), the cardiovascular system, the gastrointestinal (GI) tract, or the respiratory tract. When air passes through a narrowed flexible airway in a child, the lateral pressure that holds the airway open can drop precipitously (the Bernoulli principle) and cause the tube to close. This process obstructs airflow and produces stridor.
Option C: The most common causes of wheezing are asthma and chronic obstructive pulmonary disease (COPD), which both cause narrowing and spasms (bronchospasms) in the small airways of the lungs. However, any inflammation in the throat or larger airways can cause wheezing. Common causes include infection, an allergic reaction or a physical obstruction, such as a tumor or a foreign object that’s been inhaled.
Option D: A pericardial friction rub is pathognomonic for acute pericarditis; the rub has a scratching, grating sound similar to leather rubbing against leather. Serial examinations may be necessary for detection, as a friction rub may be transient from one hour to the next and is present in approximately 50% of cases.