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Nursing 120 final > Assessment > Flashcards

Assessment Flashcards

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1
Q

Vibration produced when patient articulates “99”

A

Tactile fremitus

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2
Q

Vesicular

A

soft and low-pitched breezy sounds heard over most of peripheral lung fields; inspiration >= expiration

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3
Q

medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration=expiration

A

Bronchovesicular

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4
Q

loud, coarse blowing sounds head over the trachea; inspiration <= expiration

A

Bronchi

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5
Q

abnormal lung sounds caused by fluid or inflammation

A

Adventitious

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6
Q

grating sound or vibration heard during inspiration and expiration

A

pleura friction rub

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7
Q

squeaky sounds heard during inspiration and expiration associated with narrowed airways

A

sibilant wheeze

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8
Q

musical sounds or vibrations commonly heard on expiration

A

sonorous wheeze

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9
Q

abnormal sounds caused by turbulence within a heart valve

A

murmurs

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10
Q

Bruit

A

turbulence within a blood vessel

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11
Q

same concentrations as body fluids

A

Isotonic fluids

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12
Q

Hypertonic solution

A

solute concentration greater than that of body fluids

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13
Q

hypotonic solution

A

solute concentration less than that of body fluids

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14
Q

fluid deficit causes

A 
vomiting
diarrhea
GI suction
sweating and warm weather
decreased intake; increased caffeine and alcohol intake
hyperthermia
diuretics
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15
Q

signs and symptoms of fluid deficit

A

weight loss
decreased skin turgor
oliguria
concentrated urine
postural hypotension
weak, rapid pulse
increased hematocrit, hemoglobin, BUN, Na, serum osmolality
Hyperthermia- increased pulse, decreased BP, disorientation
orthostatic hypotension, falls, pressure ulcers, constipation, dry oral mucous

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16
Q

increase in the interstitial compartment, intravascular compartment or both

A

fluid overload - isotonic gain

17
Q

causes of fluid overload

A 
heart failure
renal failure
Cirrhosis of the liver
excessive ingestion of Na
excessive or too rapid intravenous infusion
18
Q

signs and symptoms of fluid overload

A

edema
distended veins
increased BP
bounding pulse
crackles; increased RR, shallow respiration
decreased hematocrit and BUN (5-20 mg/dL)
weight gain

19
Q

cause of hypokalemia (<3.5 mEq/L)

A 
vomiting
gastric suction
prolonged diarrhea
diuretics and steroids
inadequate intake
20
Q

signs and symptoms of hypokalemia

A 
anorexia, N/V
weak peripheral pulses
muscle weakness, paresthesias; decreased deep tendon reflexes
impaired urine concentration
ventricular dysrhythmias 
potential for digitalis toxicity
shallow respirations
21
Q

hyperkalemia causes (> 5.0 mEq/L)

A 
renal failure 
use of K supplements
burns
crushing injuries
severe infection
K-sparing diuretics
ACE inhibitors
22
Q

signs and symptoms of hyperkalemia

A

EKG changes-peaked T waves, wide QRS complexes
dysrhythmias, ventricular fibrillation, heart block
cardiac arrest
muscle twitching and weakness
numbness in hands and feet and around mouth
nausea
Diarrhea

23
Q

causes of hyponatremia (<135 mEq/L)

A 
vomiting
diuretics
excessive administration of dextrose and water IVs
burns, wound drainage
excessive water intake
SIADH
kidneys unable to excrete free water
24
Q

sign and symptoms of hyponatreia

A 
nausea
muscle cramps
confusion
muscular twitching, coma
seizures
headache
delirium
25
Q

causes of hypernatremia (>145)

A

hyperventilation
diabetes insipidus
hypertonic tube feedings without water supplements
ingestion of OTC drugs such as Alka-Seltzer
saltwater
inadequate water ingestion

26
Q

signs and symptoms of hypernatremia

A 
Elevated temperature
weakness
Disorientation
irritability and restlessness
thirst
dry, swollen tongue
sticky mucous membranes
postural hypotension with decrease ECF
hypertension with normal or increase ECF
tachycardia
mental status changes, coma
27
Q

causes of hypocalcemia

A 
hypoparathyroidism
pancreatitis
renal failure
steroids and loop diuretics
inadequate intake
post thyroid surgery
28
Q

signs and symptoms of hypocalcemia

A 
tetany
hyperactive reflexes
confusion
paresthesias
irritability
seizures
29
Q

causes of hypercalcemia

A 
malignant neoplastic diseases
hyperparathyroidism
prolonged immobilization
excessive intake
immobility
excessive intake of calcium carbonate antacids
30
Q

signs and symptoms of hypercalcemia

A

lack of coordination
anorexia, N/V
confusion, decreased level of consciousness
personality changes
dysrthythmias, heart block, cardiac arrest

31
Q

causes of hypomagnesemia

A 
alcoholism
GI suction
Diarrhea
intestinal fistulas
poorly controlled diabetes mellitus
malabsorption syndrome
32
Q

signs and symptoms of hypomagnesemia

A 
increased neuromuscular irritability
tremors
tetany
hyperactive deep tendon reflexes
seizures
dysrhythmias
disorientation
confusion
33
Q

causes of hypermagnesemia

A

renal failure

excessive magnesium administration (antacids, cathartics)

34
Q

signs and symptoms of hypermagnesemia

A 
depresses the CNS
depresses cardiac impulse transmission
cardiac arrest
facial flushing
muscle weakness
absent deep tendon reflexes
paralysis
shallow respirations
35
Q

infiltrated IV site

A

apply warm compresses

Nursing 120 final (4 decks)

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