The nurse is assessing a patient's lungs and hears a harsh, grating sound during both inspiration and expiration. What is the most likely cause of this finding?

Correct Answer: A

Rationale: The correct answer is A: Pleural friction rub. This sound occurs due to the rubbing together of inflamed pleural surfaces during both inspiration and expiration. It is typically heard in conditions such as pleurisy or pneumonia. Rhonchi (B) are low-pitched rattling sounds typically heard during expiration, wheezing (C) is a high-pitched musical sound heard during expiration, and pneumothorax (D) presents with decreased or absent breath sounds on the affected side, not a friction rub.

Correct Answer: C

Rationale: In a blood pressure of 120/80 mmHg, 120 is the systolic pressure, the highest pressure on arterial walls during ventricular contraction . The diastolic (80) is the lowest pressure during relaxation . Pulse pressure is the difference , here 40 mmHg. The rhythmic distention describes the pulse, not a specific reading. Choice C is correct, reflecting the systolic phase of the cardiac cycle, a fundamental concept in vital sign interpretation.

Correct Answer: B

Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse reflects cardiac response but isn't directly hypothalamic. Respirations may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here. Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.

Correct Answer: B

Rationale: Temporal artery thermometers are non-invasive, posing no injury risk , ideal for newborns and children. Moisture can affect accuracy. Radiant changes are less relevant. Hair interferes. Choice B is correct, per pediatric safety standards.

Correct Answer: C

Rationale: Respiratory rate is breaths per minute , typically 12-20 for adults, counting full cycles. Inhaling or exhaling alone isn't standard. Oxygen saturation is a separate metric. Choice C is correct, per nursing definitions, a vital sign tracked to assess breathing adequacy and detect respiratory issues.