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Nursing > Assessment Findings > Flashcards

Assessment Findings Flashcards

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1
Q

Fluid volume deficit cardiovascular findings

A

thready, increased HR
decreased BP and orthostatic hypotension
flat neck
diminished peripheral pulse
decreased central venous pressure
dysrhythmias

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2
Q

Fluid volume deficit respiratory findings

A

increased rate and depth
dyspnea

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3
Q

Fluid volume deficit neuromuscular findings

A

lethargy to coma
fever
skeletal muscle weakness

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4
Q

Fluid volume deficit renal findings

A

decreased urine output

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5
Q

Fluid volume deficit integumentary findings

A

dry skin
poor turgor, tenting
dry mouth

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6
Q

Fluid volume deficit GI findings

A

decreased motility
diminished bowel sounds
constipation
thirst
decreased body weight

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7
Q

Fluid volume deficit laboratory findings

A

all increased

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8
Q

Fluid volume excess cardiovascular findings

A

bounding, increased HR
elevated BP
distended neck
elevated central venous pressure
dysrhythmias

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9
Q

Fluid volume excess respiratory findings

A

increased rate (shallow)
dyspnea
moist crackles on auscultation

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10
Q

Fluid volume excess neuromuscular findings

A

altered LOC
headache
visual disturbance
skeletal muscle weakness
paresthesias (tingling sensation)

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11
Q

Fluid volume excess renal findings

A

increased urine output

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12
Q

Fluid volume excess integumentary findings

A

pitting edema
pale, cool skin

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13
Q

Fluid volume excess GI findings

A

increased motility
diarrhea
increased body weight
liver enlargement
ascites

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14
Q

Fluid volume excess laboratory findings

A

all decreased

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15
Q

Hypokalemia cardiovascular findings

A

thready, weak, irregular pulse
weak peripheral pulse
orthostatic hypotension
dysrhythmias

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16
Q

Hypokalemia respiratory findings

A

shallow, ineffective respiratory from skeletal muscle weakness
diminished breath sounds

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17
Q

Hypokalemia neuromuscular findings

A

anxiety, lethargy, confusion, coma
skeletal muscle weakness, leg cramps
paresthesias
deep tendon hyporeflexia

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18
Q

Hypokalemia GI findings

A

decreased motility
hypoactive to absent bowel sounds
nausea, vomiting, constipation, abdominal distention
paralytic ileus (intestines do not allow food to pass through)

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19
Q

Hypokalemia lab findings

A

potassium level less than 3.5 mEq/L

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20
Q

Hypokalemia ECG findings

A

depressed ST
shallow, flat, or inverted T waves
prominent U waves

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21
Q

Hyperkalemia cardiovascular findings

A

slow, weak, irregular HR
decreased BP
dysrhythmias

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22
Q

Hyperkalemia respiratory findings

A

respiratory failure due to profound weakness of skeletal muscle

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23
Q

Hyperkalemia neuromuscular findings

A

early: muscle twitches, cramps, paresthesias
late: profound weakness

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24
Q

Hyperkalemia GI findings

A

increased motility
hyperactive bowel sounds
diarrhea

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25
Q

Hyperkalemia lab findings

A

potassium level more than 5.0 mEq/L

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26
Q

Hyperkalemia 4 ECG findings

A

flat P waves
prolonged PR intervals
widened QRS complexes
tall T waves

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27
Q

Hyponatremia cardiovascular findings

A

normovolemic: rapid pulse rate, normal BP
hypovolemic: thready, weak, rapid pulse rate; hypotension; flat neck veins
hypervolemic: rapid, bounding pulse; normal or elevated BP

28
Q

Hyponatremia respiratory findings

A

shallow, ineffective respiratory due to skeletal muscles weakness

29
Q

Hyponatremia neuromuscular findings

A

skeletal muscle weakness
diminished DTRs

30
Q

Hyponatremia CNS findings

A

headache
confusion
seizures
coma
personality changes

31
Q

Hyponatremia GI findings

A

increased motility
hyperactive bowel sounds
diarrhea
abdominal cramping

32
Q

Hyponatremia renal findings

A

increased urine output

33
Q

Hyponatremia integumentary findings

A

dry mucous membranes

34
Q

Hyponatremia lab findings

A

sodium level less than 135 mEq/L
decreased urinary specific gravity

35
Q

Hypernatremia cardiovascular findings

A

HR and BP respond to volume status

36
Q

Hypernatremia respiratory findings

A

hypervolemia: pulmonary edema

37
Q

Hypernatremia neuromuscular findings

A

early: muscles twitches, irregular muscle contractions
late: skeletal muscle weakness, diminished or absent DTRs

38
Q

Hypernatremia CNS findings

A

altered cerebral function
agitation, confusion, seizures
lethargy, stupor, coma

39
Q

Hypernatremia GI findings

A

extreme thirst

40
Q

Hypernatremia renal findings

A

decreased urinary output

41
Q

Hypernatremia integumentary findings

A

dry and flushed skin
dry and sticky tongue and mucous membranes
edema, depending on fluid volume

42
Q

Hypernatremia lab findings

A

sodium level more than 145 mEq/L
increased urinary specific gravity

43
Q

Hypocalcemia cardiovascular findings

A

decreased HR
hypotension
diminished peripheral pulses

44
Q

Hypocalcemia neuromuscular findings

A

twitches, cramps, seizures, tetany
painful muscle spasms when inactive
paresthesias
positive Trousseau’s and Chvostek’s signs
hyperactive DTRs
anxiety. irritability

45
Q

Hypocalcemia GI findings

A

increased motility
hyperactive bowel sounds
diarrhea
cramping

46
Q

Hypocalcemia lab findings

A

calcium level less than 9.0 mg/dL

47
Q

Hypocalcemia ECG findings

A

prolonged QT and ST intervals

48
Q

Hypercalcemia cardiovascular findings

A

early: increased HR
late: bradycardia to cardiac arrest
increased BP
bounding, full peripheral pulses

49
Q

Hypercalcemia respiratory findings

A

ineffective respiratory due to profound skeletal muscle weakness

50
Q

Hypercalcemia neuromuscular findings

A

profound muscle weakness
diminished or absent DTRs
disorientation, lethargy, coma

51
Q

Hypercalcemia GI findings

A

decreased motility
hypoactive bowel sounds
constipation, anorexia, nausea, abdominal distention

52
Q

Hypercalcemia lab findings

A

calcium level more than 10.5 mg/dL

53
Q

Hypercalcemia ECG findings

A

shorten ST segments
widened T waves
heart block

54
Q

Hypomagnesemia cardiovascular findings

A

tachycardia
hypertension

55
Q

Hypomagnesemia respiratory findings

A

shallow

56
Q

Hypomagnesemia neuromuscular findings

A

twitches, paresthesias
positive Trousseau’s and Chvostek’s signs
Hyperreflexia
tetany, seizures

57
Q

Hypomagnesemia CNS findings

A

irritability
confusion

58
Q

Hypomagnesemia lab findings

A

magnesium level less than 1.8 mEq/L

59
Q

Hypomagnesemia ECG findings

A

depressed ST segments
tall T waves

60
Q

Hypermagnesemia cardiovascular findings

A

bradycardia
hypotension

61
Q

Hypermagnesemia respiratory findings

A

insufficient if respiratory weakness is present

62
Q

Hypermagnesemia neuromuscular findings

A

diminished or absent DTRs
skeletal muscle weakness

63
Q

Hypermagnesemia CNS findings

A

drowsiness, lethargy, coma

64
Q

Hypermagnesemia lab findings

A

magnesium level more than 2.6 mEq/L

65
Q

Hypermagnesemia ECG findings

A

prolonged PR intervals
widened QRS complexes

Nursing (6 decks)

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