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Fall 2015 Nursing School > 319 Exam 2 > Flashcards

319 Exam 2 Flashcards

1
Q

Cardiac subjective data

A 
CP
SOB
Cough
Any Hx of HTN, MI, CAD
PND
Exercise intolerance 
Palpitations 
Claudication
Edema
Syncopy
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2
Q

Respiratory subjective data

A 
Cough
SOB
Orthopnea 
Chest pain
Past history of respiratory infection
Trauma
Surgery
PMH
Environmental exposures
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3
Q

Subjective in common to both respiratory and cardiovascular

A

SOB
CP
Cough
Exercise intolerance

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4
Q

Respiratory Inspection

A

Symmetry?
Cyanosis?
Lesions?

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5
Q

Respiratory palpation

A

Thoracic expansion

Tactile fremitus (symmetrical vibration)

Tenderness

Lumps

Temperature

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6
Q

Palpation for tenderness, lumps, temperature using…

A

Fingers

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7
Q

Respiratory percussion

A

Resonance

Diaphragmatic excursion

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8
Q

High pitched, loud

A

Bronchial

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9
Q

Moderate, moderate

A

Bronchovesicular

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10
Q

Low pitch, soft

A

Vesicular

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11
Q

Broncophony

A

Say 99, hear barely

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12
Q

Egophony

A

Say eeee, expect eeee

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13
Q

Whispered pectoriloquy

A

Whispers, should be barely audible

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14
Q

S1 is from…

A

AV valves closing

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15
Q

S1 is loudest near the

A

Apex

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16
Q

S2 is from…

A

Closing of semilunar valves

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17
Q

S2 is loudest at the…

A

Base

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18
Q

Respiratory nursing diagnosis

A

Restlessness r/t dyspnea

Cyanosis r/t air hunger

Impaired cognitive function r/t ineffective breathing patterns

Ineffective airway clearance r/t inability to cough effectively

Impaired gas exchange r/t tachypnea

Activity intolerance r/t accessory muscle use

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19
Q

Cardiac nursing diagnosis

A

Activity intolerance r/t CP

Altered tissue perfusion r/t decreased cardiac output

Sensory alteration-tactile r/t impaired circulation

Impaired healing-foot ulcers r/t impaired circulation

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20
Q

For the respiratory exam auscultate using the…

A

Diaphragm

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21
Q

Crackles are heard during…

A

Inspiration

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22
Q

Friction rubs are heard during…

A

Inspiration and expiration

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23
Q

Not cleared by coughing

A

Crackles

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24
Q

Course sounds cleared with coughing…

A

Rhonchi

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25
Q

High-pitched piercing sound

A

Stridor

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26
Q

This sound is indicative of upper airway obstruction

A

Stridor

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27
Q

Apgar scoring system

A

HR

Respiratory effort

Muscle tone

Color

Reflex irritability to

28
Q

The first BP change seen in shock is a…

A

Narrowing pulse pressure (Diastolic BP starts to rise)

29
Q

What is a good heart rate?

A

60 to 100 BPM traditional

50 to 90 BPM AHA

30
Q

Early signs of shock

A 
Tachycardia
Tachypnea
BP varies/pulse pressure narrows
Decreased urinary output
Elevated blood glucose
31
Q

What three positions is orthostatic hypotension checked?

A

Lying
Sitting
Standing

32
Q

What signifies orthostatic hypotension?

A

Drop in BP more than 20 mm systolic

Increase in HR more than 20 BPM

33
Q

Skin turgor is not helpful in…

A

Middle-aged/older adults

34
Q

Signs of poor perfusion

A

Skin color

Skin temperature

Capillary refill

Peripheral pulses

35
Q

Different cardiac symptoms in women

A

Shortness of breath

Fatigue

Epigastric symptoms

Neurologic symptoms

36
Q

Cases where cardiac disease presents without chest pain

A

Elderly

Diabetics

Alcoholics and drug abusers

Previous mediastinal or thoracic surgery

37
Q

For cardiovascular inspection what is normal?

A

No pulsation or apical pulsation

38
Q

For cardiovascular palpation what is normal?

A

Only the apical impulse should be felt

39
Q

S1 is the start of

A

Systole

40
Q

S2 is the start of

A

Diastole

41
Q

S3

A

Ventricular gallop

Indicative of LV failure

42
Q

S4

A

Associated with HTN and CAD

43
Q

Murmurs are graded on a scale of…

A

1 to 6

44
Q

Problem with the valve not opening fully

A

Stenosis

45
Q

Problem with valve not staying closed completely

A

Regurgitation

46
Q

MS.ARD

A

Mitral stenosis and aortic regurgitation cause diastolic murmurs

47
Q

MR. PASS

A

Mitral regurgitation and Pulmonic or aortic stenosis cause systolic murmurs

48
Q

Peripheral vascular inspection

A 
Color
Clubbing
Capillary refill
Temperature
Edema 
Ulceration 
Hair distribution
49
Q

Auscultate to the carotids with

A

Bell

50
Q

5 locations of auscultation for bruits

A 
Carotid
Abdominal
Renal
Iliac
Femoral
51
Q

What angle is JVP measured at?

A

45 degrees

52
Q

What is a normal JVP measurement?

A

2 cm or less

53
Q

Peripheral Pulse are measured on a scale of

A

0-3+

54
Q

A normal peripheral pulse is

A

2+

55
Q

Weak thready pulse

A

Peripheral artery disease PAD

Decreased CO

56
Q

Regular rhythm, alternating weak strong

A

Pulsus Alternans

Indicative of Heart Failure

57
Q

Pulse weaker inspiration, stronger expiration

A

Pulsus Paradoxus

Indicative of Tamponade

58
Q

Symptoms for PAD

A 
Calf/thigh pain
Worse with activity 
Color change
Temp change
Loss of hair
Slow wound healing 
Diminished pulses
59
Q

Palpation for Peripheral Vascular

A

Warmth
Tenderness
Edemar

60
Q

Edema scale range

A

1+ to 4+

61
Q

Causes of pitting edema

A 
Venous stasis
Heart failure
Liver failure 
Renal failure 
Poor lymphatic drainage
62
Q

Venous stasis causes

A

Pregnancy
Obesity
DVT/VTE
Long periods sitting/standing

63
Q

Peripheral vascular arterial deficiency

A 
Ischemic ulcer 
Hairlessness
Cool to touch
Diminished pulses
Claudication (leg cramps)
Pain relieved by rest
Color changes (cyanosis, e palor, d rubor)
64
Q

Ankle-brachial pressure index normal range

A

0.9-1.2

65
Q

DVT symptoms

A

Acute pain
Edema
Redness
homan’s sign (lower leg)

Fall 2015 Nursing School (17 decks)

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