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Health Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Traumatic Brain Injury

A

Blow to the head that interferes with brain function

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2
Q

Which brain injury is most mild?
Direct
Acceleration/Deceleration
Blast

A

Direct

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3
Q

What does a direct brain injury do that an acceleration/deceleration or blast injury will not do?

A

Resolves in 10 days

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4
Q

Concussion symptoms

A
  • Headache
  • Nausea/vomiting
  • Sensitivity of light and/or sound
  • Changes to reaction in time, balance, and coordination
  • Changes in memory, judgment, and/or speech
  • Sleep pattern changes
  • Risk for reoccurrence higher in first 10 days following initial concussion
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5
Q

Is headache associated with concussion?

A

Yes

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6
Q

Is nausea associated with concussion?

A

Yes

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7
Q

What sensitivities/phobias are associated with concussions?

A

Photophobia and phonophobia

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8
Q

Changes in memory, judgement and speech occur with what type of injury

A

Concussion

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9
Q

With what head injury are sleep patterns altered?

A

Concussion

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10
Q

With a concussion, what is the risk in the next 10 days?

A

Reoccurrence

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11
Q

What is the leading cause of TBI in those older and younger than 65?

A

Over 65 - falls
Under 65 - transportation accidents

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12
Q

Worldwide, TBI is the leading cause of what from accidents?

A

Accident related death and disability.

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13
Q

Worldwide, TBI is the leading cause of what condition?

A

Seizure disorders

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14
Q

These are the symptoms of what?
- Memory impairments
- Disturbed thought processes
- Spastic or involuntary movements
- Personality changes
- Vision and or hearing changes
- Seizures

A

Traumatic Brain Injury

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15
Q

Three primary headaches

A

Tension, migraines, cluster

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16
Q

What is the process for which three primary headaches evolve?

A

Tension - process unclear
Migraines - neuronal dysfunction
Cluster - process unclear

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17
Q

What is the most common headache?

A

Tension headaches

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18
Q

Which headache occurs bilaterally in head, neck, temporal region?

A

Tension

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19
Q

What headache is more mild, sometimes moderate, episodic or chronic, associated symptoms are light sensitivity, no nausea

A

Tension

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20
Q

Stress makes what headache worse, along with aggravation by sustained positions, sleep disturbances

A

Tension

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21
Q

What headache is unilateral and:
Lasts 4-72 hours
Reoccurring
Familial
More woman than men
Connection between estrogen and migraines (pregnant now have them)
Nausea
Triggers – food, alcohol, period, stress, high altitudes
Photo and phonophobia

A

Migraines

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22
Q

What headache has auras (sensory, buzzing, pins and needles, blurred vision), prodrome (behavioral – change in mode, irritability, mood change)

A

Migraines

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23
Q

What headache presents with photophobia and phonophobia?

A

Migraines

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24
Q

What headache has the following characteristics:
Higher in males
Usually during 6-12 month with repeat, usually behind one eye or temple
Intense so usually go to ER with first one.
Can cause swelling around eyes, runny nose,
Rare

A

Cluster headache

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25
Q

What type of headaches is a category containing more pronounced forms of tension,migraine, and medication overuse headachesthat last more than 15 days a month for more than 3 months?

A

Chronic daily headache

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26
Q

The following are risk factors for what type of headache:
Caffeine ingestion
Obesity
Use of headache medications (>10 days a month) predisposed to these
Sleep and mood disorders

A

Chronic daily headache

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27
Q

What is SNOOP used for?

A

Red flag detection tool for secondary headaches

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28
Q

What does SNOOP stand for?

A

Systemic symptoms and secondary risk factors
Neurologic symptoms/signs
Onset/Other associated conditions
Positional/Prior HA/Papilledema (a condition in which increased pressure in or around the brain (intracranial pressure) causes swelling of the part of the optic nerve inside the eye (optic disc).

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29
Q

What is Papilledema?

A

Papilledema (a condition in which increased pressure in or around the brain (intracranial pressure) causes swelling of the part of the optic nerve inside the eye (optic disc).

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30
Q

What is papilledema associated with?

A

SNOOP - Red flag detection tool to rule out secondary headaches.

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31
Q

What is a secondary headache that is “the worst of my life?”

A

Subarachnoid hematoma (Thunderclap headache)

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32
Q

Are secondary headaches more severe or less severe than primary headaches?

A

More severe.

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33
Q

What are some secondary headaches?

A

Glaucoma, subarachnoid hemorrhage, post-concussion headache, meningitis, brain tumor

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34
Q

What is a thunderclap headache?

A

Subarachnoid hemorrhage

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35
Q

Three types of traumatic brain injuries?

A

Direct impact, acceleration/deceleration, blast

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36
Q

What type of traumatic brain injury is mild and resolved in 10 days?

A

Direct impact.

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37
Q

What is a traumatic brain injury?

A

Blow to head that interferes with the function of the brain.

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38
Q

Signs of concussion

A

Headache
Nausea/vomiting
Sensitivity of light and/or sound
Changes to reaction in time, balance, and coordination
Changes in memory, judgment, and/or speech
Sleep pattern changes
Risk for reoccurrence higher in first 10 days following initial concussion

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39
Q

Where is the anterior triangle of the neck located?

A

Edge of mandible, anterior length of sternocleidomastoid muscle

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40
Q

Where is the posterior triangle of the neck located?

A

Posterior edge of sternocleidomastoid muscle, anterior edge of trapezoid, superior border of clavicle.

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41
Q

What is Hirsutism?

A

A condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back.

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42
Q

Three things to check on physical examination of the head.

A

Hair – quantity, distribution, and texture, Hirsutism
Scalp – scaling, lumps, lesions
Skull – size and contour, deformities, lumps, tenderness

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43
Q

Abnormal findings on infant head.

A

Bulging, shrunken, small or delayed closing in fontenelles. Anterior should close between 9 months – 2 years.
Hydrocephalus.

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44
Q

Hydrocephalus

A

Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head

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45
Q

What is an obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head

A

Hydrocephalus

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46
Q

Facial assessment

A

• Note facial expression and appropriateness to behavior or reported mood
• Facial structures always should be symmetric
• Note symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth
• Note any abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation), or abnormal swellings
• Note any involuntary movements (tics) in facial muscles; normally none occur

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47
Q

Exophthalmos

A

The protrusion of one eye or both anteriorly out of the orbit (bulging).

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48
Q

What is the protrusion of one eye or both anteriorly out of the orbit?

A

Exophthalmos

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49
Q

Cushing Disease normal cause

A

Usually from high dose corticosteroids

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50
Q

Visual symptoms of Cushing Disease

A

Moon cheeks, red cheeks, excessive hair growth especially of chin, mustache, sideburns.

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51
Q

Moon cheeks, red cheeks, excessive hair growth especially of chin, mustache, sideburns are symptoms of what?

A

Cushing Disease

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52
Q

What condition is caused when kidneys pass too much protein in urine and results from high bp, type II diabetes?

A

Nephrotic syndrome

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53
Q

Edematous meaning

A

swollen with an excessive accumulation of fluid

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54
Q

What condition presents with these symptoms: Face is edematous and pale. Swelling around eyes in morning. Eyes slits when edema is bad.

A

Nephrotic syndrome

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55
Q

Nephrotic syndrome presents with what symptoms?

A

Face is edematous and pale, swelling around eyes worse in morning.

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56
Q

Acromegaly is a problem of what gland?

A

Pituitary

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57
Q

What is acromegaly?

A

Excessive growth caused by too much growth hormone produced by pituitary, Bone and soft tissue affected.

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58
Q

Facial abnormalities in children

A

Fetal alcohol syndrome – damage neural crest, lower jaw recessed, etc.

Down syndrome, flatter feature, up-slanting eyes, low set smaller ears, smaller neck.

Atopic (allergic) facies
• Allergic salute
• Allergic (shiners)
• Crease above bottom nose
• Shiners (swollen eyes)

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59
Q

Atopic (allergic) facies in children include:

A

• Allergic salute
• Allergic (shiners)
• Crease above bottom nose
• Shiners (swollen eyes)

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60
Q

The following of symptoms of what in children:
• Allergic salute
• Allergic (shiners)
• Crease above bottom nose
• Shiners (swollen eyes)

A

Atopic (allergic) facies

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61
Q

Disease that effects the parotid gland

A

Mumps most common, staph, strep, fungus

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62
Q

Submandibular gland issues

A

Swelling, usually stones- massage, more fluids

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63
Q

Lymph node assessment

A

Pads of index and middle fingers palpate in circular motion
Usually examine both sides at once
Patient relaxed with neck flexed forward slightly

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64
Q

Verchow’s node

A

It is the thoracic duct end node

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65
Q

Are lymph nodes usually movable?

A

Yes

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66
Q

Abnormal lymph node findings?

A

Tender = inflammation
Unilateral/fixed/hard = malignancy?
Soft, movable – either normal for them or infection.
Enlarged – examine regions from which they drain (upstream)
Diffuse lymphadenopathy = HIV/AIDS
Should be able to move up/down, around.

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67
Q

Lymphadenopathy

A

A disease of the lymph nodes, in which they are abnormal in size or consistency

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68
Q

From which two directions can you palpate the thyroid?

A

From anterior position or posterior position

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69
Q

What type of lighting helps accommodate inspection?

A

Tangential.

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70
Q

Causes of these thyroid conditions:
Diffuse enlargement
Single nodule
Multinodular goiter

A

Diffuse enlargement: Graves, Hashimoto’s, Goiter
Cyst, benign tumor
Malignancy

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71
Q

Symptoms of hypothyroidism

A

Swelling of face, lips, eyelid, tongue​
Coarse hair

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72
Q

Symptoms of hyperthyroidism

A

Visual changes(Myxedema)
Exophthalmos
Stare and lid lag
Fine hair

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73
Q

What is an impact test?

A

HIT is a tool used to measure the impact headaches have on your ability to function on the job, at school, at home and in social situations. Your score shows you the effect that headaches have on normal daily life and your ability to function.

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74
Q

PQRST test for headaches

A

PQRST of the pain: provocation, quality, region, strength and time course

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75
Q

Pale turbinates associated with what condition?

A

Allergies

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76
Q

What is ptosis?

A

When the upper eyelid droops over the eye

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77
Q

What is miosis?

A

Excessive constriction of the pupil of the eye

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78
Q

What type of headache presents with “that started like the flip of a switch!”

A

Subarachnoid hemorrhage

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79
Q

Three parts of successful interview

A
  • Gathers complete and accurate data
  • Establishes and builds rapport and trust for person to share relevant data
  • Begins teaching for health promotion and disease prevention
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80
Q

Stages of the interview

A
  • Pre-interview: self reflection, review the records, set goals, review own clinical behavior and appearance.
  • Introduction: establish rapport, review agenda
  • The working phase: (data collection)
  • Termination: Closing the interview, review/summarize with the patient, make sure I understand everything
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81
Q

What is the pre-interview stage of a client interview

A

Self reflection, review the records, set goals, review own clinical behavior and appearance.

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82
Q

In what stage of the client interview do you establish rapport, review agenda?

A

Introduction

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83
Q

In what phase of the client interview does the nurse collect data?

A

The working phase

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84
Q

What happens in the termination phase of a client interview?

A

Review/summarize

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85
Q

In the interview, what type of information are you collecting?

A

Subjective

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86
Q

What are the attributes of a symptom?

A

Onset
Location
Duration
Characteristics
Associated manifestations
Relieving factors
Treatment

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87
Q

Which of the following are internal and what are external factors of the process of communication?
Refuse interruptions, dress, listening, physical environment, liking others, note-taking, ensure privacy, empathy.

A

Internal:
Listening
Empathy
Liking others

External:
Ensure privacy
Refuse interruptions
Physical environment
Dress
Note-taking

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88
Q

Questions during the patient interview should proceed from what type to what type?

A

General to specific

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89
Q

What two types of questions exist in the interview?

A

Open and closed-ended.

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90
Q

False reassurance, giving unwanted advice, using authority, using avoidance language, engaging in distancing symptom from client, using professional jargon, leading or biased questions, talking too much, interrupting with “why” questions are examples of what?

A

Non-therapeutic communication

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91
Q

Physical appearance, body posture, gestures, facial expression, eye contact, voice and touch are what type of behaviors?

A

Non-verbal behaviors

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92
Q

Reassurance, silence/active listening, validation, reflection, empathy, clarification, interpretation, explanation, summery are part of what type of communication?

A

Therapeutic communication

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93
Q

Two types of communication

A

Therapeutic and non-therapeutic

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94
Q

The following are present what type of considerations when interviewing a patient?

Parent
Infant
Toddler
Schol-age
Adolescent
Older adult

A

Developmental considerations

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95
Q

How do you talk to an elderly person?

A

Address by proper name
Speak slowly
Adjust tone/volume (do not shout)
Sit/lean at eye level
Touch
Use multiple segments to complete the interview

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96
Q

Should you use multiple segments to complete an interview with an elderly person?

A

Yes

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97
Q

If someone is acutely ill, should you complete the entire interview?

A

No.

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98
Q

Should you consider cultural considerations when interviewing?

A

Yes

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99
Q

Four parts of motivational interviewing (OARS).

A

Open-ended questions
Affirmation
Reflective listening
Summarize and teach back

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100
Q

When an emotional cue surfaces in an interview, what’s the mnemonic for responding?

A

NURS
Naming- “That sounds like a scary experience.”
Understanding - It’s understandable to feel that way.”
Respecting - You’ve done better than most…”

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101
Q

The NURS mnemonic is applicable to what?
Naming- “That sounds like a scary experience.”
Understanding - It’s understandable to feel that way.”
Respecting - You’ve done better than most…”

A

Responding to a patient who is emotional.

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102
Q

Two kinds of health history

A

Risk reduction
Focused or problem-solving assessment

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103
Q

Nursing analysis clinical reasoning four steps (ICIM)

A
  • Identify abnormal/positive findings
  • Cluster the findings
  • Interpret the findings
  • Make hypothesis
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104
Q

Components of health history

A

Identifying data
Chief complaint
History of present illness
Past history
Family history
Review of systems
Health patterns

105
Q

What are the identifying data in a health history

A

Name
DOB
Gender
Occupation
Marital status
Primary language

106
Q

What part of the interview process is the chief complaint included?

A

Health history - Assessment

107
Q

How do stethoscopes work?

A

They drown out background noise

108
Q

What type of percussion sound do places with air make?

A

Produce louder, deeper and longer sound because it vibrates freely.

109
Q

What type of percussion sound do places without make?

A

Produce softer, higher pitch, shorter sound because it doesn’t not vibrate as easily.

110
Q

Characteristics of percussion sounds

A

Resonance (lungs)
Hyperresonance (air trapped in lungs)
Tympany
Dull (liver)
Flat (bone)

111
Q

Four parts of the comprehensive adult physical exam

A

IPPA:
Inspection
Palpation
Percussion
Auscultation (except over abdomen do auscultation second)

112
Q

What three characteristics of percussion occur over areas with air?
Without air?

A

Louder, higher, longer
Softer, deeper, shorter

113
Q

When examining kids, what part of the body do you start with?

A

The periphery, not the face.

114
Q

What part of the stethoscope picks up high pitched sounds?

A

The diaphragm

115
Q

What part of the stethoscope picks up low-pitched sounds?

A

The bell

116
Q

What parts of the body do we listen to with the diaphragm of the stethoscope?

A

Lungs, bowels, breath

117
Q

What parts of the stethoscope do we listen to with the bell of the stethoscope?

A

Murmurs, extra heart sounds.

118
Q

Objectives of the general survey of the initial inspection of a patient.

A

Physical appearance
Body structure
Mobility
Behavior

119
Q

BMI levels

A

Underweight < 18.5
Normal 18.5 - 24.9
Overweight 25 - 29.9
Obesity 30 - 39.9
Extreme obesity > or = 40

120
Q

What levels are the following BMIs:
30 - 39.9
< 18.5
18.5 - 24.9
> or = 40
25 - 29.9

A

Underweight < 18.5
Normal 18.5 - 24.9
Overweight 25 - 29.9
Obesity 30 - 39.9
Extreme obesity > or = 40

121
Q

Increased risk of heart disease and obesity-related diseases for women and men with a waist circumference greater than what?

A

Women > 35 in
Men > 40 in

122
Q

What is Marfan syndrome?

A

Genetic problem with the connective tissue that Abraham Lincoln and Michael Phelps have.

123
Q

Nursing analysis: Steps in clinical reasoning.

A

Identify abnormal/positive findings
Cluster the findings
Interpret the findings
Make hypothesis

124
Q

What part of the nursing care plan contains these steps?
Based on real or potential health problems
Based on assessment data
Sets stage for remainder of care plan

A

Nursing diagnosis

125
Q

Temperature normal

A

98.6°F, range 96.4° - 99.1° F
37°C, range 35.8° - 37.3° C

126
Q

What part of the brain regulates temperature?

A

Hypothalamus

127
Q

In what demographic is the temperature regulations deficient?

A

Infants

128
Q

What is thermoregulation?

A

The regulation of the temperature through feedback mechanism

129
Q

Rectal temps measure how much different than oral?

A

1 degree fahrenheit

130
Q

Stroke volume

A

70 mL
Amount of blood heart pumps into the aorta with every beat

131
Q

What does pulse give?

A

Rate and rhythm

132
Q

How long do you take a pulse?

A

30 seconds. If irregular, 1 minute.

133
Q

Pulse rate

A

60 - 100 bpm

134
Q

Bradycardia

A

> 60 bpm

135
Q

Tachycardia

A

> 100 bpm

136
Q

When is tachycardia normal?

A

During exercise or anxiety

137
Q

When is bradycardia normal?

A

In well conditioned athletes

138
Q

The force of the pulse is rated how?

A

0 absent
1+ weak, thready
2+ normal
3+ full, bounding

139
Q

Normal respiration rate is counted how?

A

Count for 30 seconds, if irregular, count for 1 minute

140
Q

What is blood pressure?

A

The force of blood against the vessel wall.

141
Q

Systolic pressure -

A

Maximum pressure on an artery during left ventricular contraction (systole)

142
Q

Diastolic pressure -

A

Pressure against a vessel wall when heart rests

143
Q

High BP

A

Over 140/90

144
Q

Normal BP

A

Below 120/80

145
Q

Elevated BP

A

120 - 129/<80

146
Q

Hypertension

A

Stage I - 130-139/80-89
Stage II - > or = 140; = or > 90

147
Q

BP values

A

Normal below 120/80
Elevated 120 - 129/>80
Hypertension Stage I - 130-139/80-89
Hypertension Stage II - > or = 140, > or = 90

148
Q

What BP errors result in lower BP than should be

A

BP cuff too big
Arm above heart
Repeating assessment too quickly
Pressing stethoscope too tightly to brachial artery

149
Q

What artery is being used to determine BP?

A

Brachial artery

150
Q

Errors that result in too high a BP.

A

Cuff too small
Too loose
Arm below heart level
Inflating/deflating cuff to slowly
Deflating cuff too quickly

151
Q

Orthostatic BP is what two measurements?

A

BP and pulse

152
Q

Abnormal orthostatic BP levels?

A

Systolic drop 20 mm
Diastolic drops 10 mm

153
Q

What does O2 sat measure

A

Light absorbed by oxyhemoglobin and unoxygenated hemoglobin

154
Q

O2 acceptable sat rate?

A

> 95%

155
Q

Oxygen saturation is an indicated of oxygen available to what

A

Deliver to tissues

156
Q

Hypoxia

A

Inadequate amount of oxygen available at the cellular level

157
Q

What pulse do you palpate/auscultate with infants?

A

apical pulse

158
Q

Dirunal

A

24 hour cycle

159
Q

In children older than 2 use what site for pulse?

A

Radial

160
Q

Use what size of stethoscope and BP cuff for children

A

Children-sized BP cuff and stethoscope

161
Q

Crying might elevate pediatric BP by how much?

A

30-50 ?mm Hg

162
Q

Does the heart rate vary more with adults of children?

A

Children

163
Q

Should you take the vitals of a crying infant

A

No. Allow the child to settle for 5-10 minutes.

164
Q

Difference between nociceptive and neuropathic pain?

A

Nociceptive: Injury to tissues
Neuropathic: injury to peripheral nerves

165
Q

What are nociceptors?

A

Specialized nerve endings that detect painful sensations and transmit to CNS.

166
Q

Nociception involves what four pain mechanisms?

A

Transduction - stimuli causes tissue damage
Transmission - relay from peripheral to CNS (dorsal horn processing, thalamus, cerebral cortex).
Perception - conscious awareness
Modulation - Pain inhibited by modulators

167
Q

Classifications of pain

A

Somatic and visceral

168
Q

Somatic pain

A

From BVs, joints, tendons, muscles, bone

169
Q

Visceral pain

A

From organs, referred pain, neuropathic, phantom

170
Q

Inhibitory neurotransmitters are in insufficient supply until birth at full term (T/F)?

A

True

171
Q

Does a premie have a higher sensitivity to painful stimuli?

A

Yes

172
Q

What is the red flag for weight loss?

A

More than 5% in 6 months

173
Q

Side effects of overnutrition and weight gain.

A

Reduced metabolism
Accumulation of body fluids
Depression, eating disorders

174
Q

Percentage of adults in the US who are overweight or obese.

A

73.6%

175
Q

Percentage of children who are overweight or obese.

A

35.4%

176
Q

Cracking around lips and in corners of mouth cause by?

A

B vitamin deficiency

177
Q

Pale conjunctiva can be caused by a deficiency of?

A

Iron

178
Q

Dark circles under the eyes can be a sign of?

A

Iron deficiency

179
Q

Adventitious sounds in the lungs can indicate what?

A

Hydration level

180
Q

Capillary refill is an indication of what?

A

Perfusion

181
Q

How can you check for perfusion?

A

Press nail bed. If takes >3 seconds to return to pink, is compromised perfusion

182
Q

Jugular distension is related to?

A

Heart failure, chronic condition of liver or kidneys, impaired ventricular function of heart

183
Q

Heart failure, chronic condition of liver or kidneys, impaired ventricular function of heart are related to what condition?

A

Jugular distention

184
Q

Ecchymosis

A

Discoloration due to bruising

185
Q

Osteomalacia

A

Vit D deficiency

186
Q

Marasmus

A

Severe calorie deficiency stunted growth, muscle wasting off growth chart.

187
Q

Health promotion and counseling four steps

A
  1. Measure BMI and assess risk factors
  2. Assess dietary intake
  3. Assess patient’s willingness to change
  4. Provide counseling about nutrition and exercise
188
Q

Recommended guidelines for weight loss

A

Reduce by 500 (to 1000) calories/day
10% reduction in 6 months
Weight loss of 1/2 to 1 pound per week
Combine with nutrition and exercise

189
Q

Exercise guidelines for weight loss

A

2 1/2 hours per week of moderate exercise
1 1/4 hours of vigorous exercise

190
Q

Polypharmacy

A

Multiple medications

191
Q

What two sinuses can be palpated?

A

Frontal and Maxillary (ethmoid and sphenoid can’t be palpated)

192
Q

What part of the pharynx contains the tonsils?

A

Oropharynx

193
Q

What part of the pharynx contains the Eustachian tubes

A

Nasopharynx

194
Q

Mumps affects which gland?

A

Parotid - largest salivary gland

195
Q

How many permanent teeth are there?

A

32

196
Q

Three parts of a tooth

A

Crown, neck, root

197
Q

Bacteria in the mouth contribute to what?

A

Plaque formation via inflammation and increase risk of heart attack 200-300%

198
Q

Babies drool at what age?

A

At 3 mouths start to salivate. Will drool for a few months before start to swallow saliva.

199
Q

Babies have how many deciduous teeth?

A

20

200
Q

When do deciduous teeth erupt?

A

6 months - 2 years

201
Q

When do kids start to lose deciduous teeth?

A

6 -12 years

202
Q

Major cause of decrease saliva in elderly is what?

A

Medication

203
Q

Dysphagia

A

Trouble swallowing

204
Q

Epistaxis

A

Nose bleed

205
Q

Gag reflex tests what cranial nerves

A

Gag reflex - glossopharyngeal and vagus

206
Q

Stick out tongue test what cranial nerve?

A

Hypoglossal

207
Q

Halitosis

A

Bad breath

208
Q

Get black tongue or candida by taking what?

A

Antibiotics

209
Q

Uvula rising midline on “ah” tests what cranial nerve

A

Vagus

210
Q

What condition can occur in the lungs with dehydration

A

Pleural friction

211
Q

When the pleural space fills with air, is there an increase or decrease in lung expansion?

A

Decrease

212
Q

By supplying oxygen and expelling carbon dioxide, what two levels are maintained in the body?

A

pH and acid/base balance

213
Q

Breathing is run by what two centers in the brain?

A

Pons and medulla

214
Q

A change in what levels is the feedback loop in the brain for breathing?

A

Carbon dioxide and oxygen

215
Q

Negative or positive pressure?
Inspiration
Expiration

A

Inspiration - negative pressure
Expiration - positive pressure

216
Q

What muscle does 80% of the work of breathing?

A

Diaphragm

217
Q

At what stage does fetus have lung surfactant?

A

32 weeks

218
Q

The elderly experience what changes in vital capacity and residual lung volumes?

A

Vital capacity decreases
Residual volume increases

219
Q

In what condition does a patient do purse-breathing?

A

COPD

220
Q

What to do in pursed lip breathing to strengthen diaphragm?

A

Exhale through pursed lips, inhale through nose with mouth closed. Also provides resistance.

221
Q

Clubbing of nails occurs when?

A

With chronic hypoxia or chronic heart disease that leads to decreased oxygen

222
Q

Why do patient’s develop barrel chest

A

Lungs have trapped air in them from COPD so diaphragm becomes flattened from the force and does not work. Becomes immobile.

223
Q

Five positions?

A

Supine (on back)
Prone (on stomach)
Left lateral recumbent
Right lateral recumbent
Fowler’s (45° - Semi-Fowlers or 90°- high Fowlers)
Trendelenberg (inverted)

224
Q

What are intercostal/substernal retractions

A

Sucked in lungs of infant who can’t breathe

225
Q

Through what structure do babies breathe?

A

Through their nose

226
Q

At what level do you place your hands to check for inspiration symmetrically anteriorly and posteriorly?

A

T9/T10

227
Q

When does unequal expansion occur in the chest?

A

When breathing occurs only on one side, as in pleurisy.

228
Q

Tactile fremitus is felt how?

A

By having patient repeat “99” and holding hand over lungs while bronchi and parenchyma transmit vibrations.

229
Q

Is tactile fremitus stronger over structures with air or without?

A

Exaggerated over mass; decreased over air (normal lung tissue) and further decreased with too much air (COPD

230
Q

On percussion, normal lungs produce what?

A

Resonance, low-pitched hollow sound.

231
Q

On percussion, fluid or a solid mass presents how?

A

Dullness

232
Q

On percussion, too much air in the lungs presents how?

A

Hyperresonance

233
Q

Three types of normal breath sounds

A

Bronchial/Tracheal (over bronchii - high pitched harsh)
Bronchovesicular - over major bronchials where not many ariolar (medium pitch)
Vesicular - over air sacs (low piych (wind through the trees)

234
Q

Crackles are what type of sound?

A

“Hair in front of air” Presence of fluid - possible heart failure. Fluid overload in lower lobes

235
Q

Wheezing is what type of sound?

A

Edematous airway, airflow obstruction, high-pitched whistling (asthma)

236
Q

Rhonchi are what type of sound?

A

Thick mucous usually in larger airways - “Rhonchi in the bronchi.” Snoring.

237
Q

Stridor are what type of sound?

A

Obstruction in larynx or trachea, medial emergency - foreign body in kids. Hear when walk into room.

238
Q

What of the four lung sounds is an indication of heart failure?

A

Crackles

239
Q

Which of the four lungs sounds is an indication of asthma?

A

Wheezing

240
Q

Which of the four lung sounds is a medical emergency?

A

Stridor

241
Q

With Bronchophony, sound travels better through masses than air (T/F?)

A

True

242
Q

Normal O2 Sat level?

A

Normal is > 95

243
Q

At what sat level should patient’s receive O2?

A

90 or below

244
Q

Hypoxia

A

Inadequate level of O2 at the cellular level

245
Q

Hyoxemia

A

Inadequate level of O2 in arterial blood.

246
Q

What is FIO2?

A

Fraction of inspired O2

247
Q

What is the FIO2 of room air?

A

21%

248
Q

What is the maximum liters of air that can be delivered via nasal cannula?

A

4L

249
Q

What is Scoliosis

A

Curvature of the spine - may decrease lung volume

250
Q

Pectus Excavatum

A

Hole in sternum - Usually asymptomatic

251
Q

Kyphosis

A

Hunchback - potential for respiratory system compromise but usually not

252
Q

Tachyapnea

A

Rapid, shallow breathing, Increased respiratory rate >24

253
Q

Bradyapnea

A

Decreased respiratory rate, <10

254
Q

Normal respiratory rate

A

12-20 breaths/minute

255
Q

Hyperventilation

A

Increased rate/depth

256
Q

Hypoventilation

A

Irregular breaths, shallow

257
Q

Cheyne-Stokes respiration

A

Increase rate and depth and then decrease periods of apnea (Hospice)

258
Q

Primary, secondary, and tertiary prevention

A

The primary prevention approach focuses on preventing disease before it develops; secondary prevention attempts to detect a disease early and intervene early; and tertiary prevention is directed at managing established disease in someone and avoiding further complications.

259
Q

Intermittent claudication

A

Limping

Health Assessment (7 decks)

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