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Patient Evaluation > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

What are the 4 classical vital signs(VS)

A

Temp
Pulse
RR
BP

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2
Q

What is also included in initial assessment

A

Height
weight
Level of consciousness and responsiveness
General clinical impression

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3
Q

When should baseline measurements be taken

A

Upon admission
Beginning of the shift
Prior to Tx or procedure
When there is a change in pt’s condition

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4
Q

Define Trending in VS

A

A series of VS measurements over time

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5
Q

Define differential diagnosis

A

This is comparison of multiple signs and symptoms to arrive at the pt’s diagnosis

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6
Q

What is referred by some clinicians as the “fifth vital sign”

A

Pain

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7
Q

The alert pt whose orientation to time,place and person is accurate is said to be ………….. and the sensorium is considered……….

A

oriented *3
Normal

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8
Q

True or False
An abnormal sensorium may also occur as a side effect of certain medications and in drug

A

True

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9
Q

In a Glasgow scale, the objective evaluation is based on behavioural response in which 3 areas

A

Motor function
Verbal function
Eye-opening response

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10
Q

When is body temp usually the lowest and when is it the highest

A

In the morning
In the late afternoon

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11
Q

What part of the brain plays an important role in regulating heat loss and can initiate peripheral vasodilation and sweating in an effort to dissipate body heat

A

Hypothalamus

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12
Q

An elevation of body temp above normal is known as

A

Hyperthermia

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13
Q

True or False
Fever most often results from infection somewhere in the body

A

True

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14
Q

What is the term used when the body temp is below normal

A

Hypothermia

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15
Q

Describe the breathing of patient with hypothermia

A

Slow and shallow breathing and a reduced pulse rate

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16
Q

Name the sites where body temp can be measured

A

Mouth
Ear
Axilla
Rectum

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17
Q

What are the common places to measure body temp in both kids and adults

A

Mouth
Tympanic

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18
Q

What is the normal pulse rate of an adult

A

60 - 100 bpm

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19
Q

A pulse rate exceeding 100 bpm in an adult is termed

A

Tachycardia

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20
Q

A pulse rate lower than 60bpm for an adult is termed

A

Bradycardia

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21
Q

Which is the most common site for evaluation of the pulse

A

Radial

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22
Q

Define Lethargic

A

sleepy, easily aroused and responds appropriately

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23
Q

Define Obtunded

A

Difficult to arouse but responds appropriately

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24
Q

Define stupor

A

Do not wake up completely,responds to pain and slow respiration

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25
Q

Define comatose

A

Unconscious have loss of reflexes

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26
Q

What is the name of the scale that is used to assess pts level of consciousness

A

Glasgow coma scale

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27
Q

If a pt has below an 8 on the Glasgow scale what does it show and what should be done

A

Shows traumatic head injury
Intubation

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28
Q

What are some other common sites available for assessment of the pulse

A

Branchial
Femoral
Carotid arteries

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29
Q

If the strength and rhythm are normal and the pulse is irregular the pulse rate may be counted for 15 secs

A

False

Only when the pulse, strength and rhythm are normal can you count the rate for 15 secs

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30
Q

What are the terms used to describe rhythm

A

Regular
Regularly
Irregular
Irregularly

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31
Q

Describe bigeminy

A

rhythm coupled in pairs

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32
Q

A rhythm grouped as 3 beats and a pause is known as

A

Trigeminy

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33
Q

How long should you wait if a person has taken liquids or smoked before taking their pulse

A

10 - 15 mins

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34
Q

Rate the pulse volume and fullness
0 -4 …Eg. 0: Absent

A

1+ : Weak, thready
2+ : Slightly reduced
3+ : Normal
4+ : Bounding

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35
Q

What does pulse oximetry measure

A

HR and O2 saturation

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36
Q

Normal RR for an adult

A

12 - 20

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37
Q

True or False: A respiratory rate greater than 60 bpm is considered abnormal for any age and 40bpm is unusual for an adult

A

True

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38
Q

The term used to describe respiratory rates above normal

A

Tachypnea

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39
Q

A fast and deep breathing pattern is known as

A

Kussmaul breathing

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40
Q

A slow RR is referred to as

A

Bradypnea

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41
Q

Define systolic BP

A

Peak force exerted during contraction of the left ventricle

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42
Q

Define diastolic BP

A

Force occuring when the heart is relaxed

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43
Q

Define pulse pressure and what is the normal pulse pressure

A

It is the difference btn systolic and diastolic pressures
35 - 40 mmHg

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44
Q

BP persistently at or above 130/80 mmHg is termed

A

Hypertension

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45
Q

Defined as an arterial BP that is less than 90/60 mmHg in adults

A

Hypotension

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46
Q

The most common technique for measuring arterial BP uses a

A

Sphygmomanometer

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47
Q

Define the korotkoff sounds

A

Happens when blood flow in the artery resumes

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48
Q

When measuring BP what will give you a high pressure reading

A

Too narrow a cuff
Cuff applied too tight/too loose
Excessive pressure to the cuff or incomplete deflation

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49
Q

When measuring BP what will give you a low pressure reading

A

If the cuff is too wide

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50
Q

What effects does the respiratory cycle have on systolic BP during inspiration

A

It decreases

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51
Q

When is low systolic Bp during inspiration present in

A

Asthma
Cardiac tamponade

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52
Q

When does hypotension occur

A

When the left ventricle of the heart is weak

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53
Q

What medications can cause hypotension

A

Beta blockers
Diuretics

Only affects the systolic

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54
Q

Name some identifies to look for when on a pt’s face
HINT:Evaluating them

A

Acute distress
Pain
Alertness, mood and mental capacity

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55
Q

What are the 2 signs of respiratory distress

A

Cyanosis and Nasal flaring

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56
Q

If a pt has nasal flaring what does it suggest

A

Increased WOB is present

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57
Q

When is cyanotic more visible

A

When there is a significant amt of deoxygenated Hb is present

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58
Q

What parts of the body can you see central cyanosis

A

Ears
Neck
Tongue
Lips
Nose

59
Q

Define Acrocyanosis

A

A persistent, painless blusih discoloration of both hands and less commonly on both feet

60
Q

What kind of pt’s use pursed lip breathing

A

COPD

61
Q

Define mydriasis

A

Dilated and fixed eyes

62
Q

Define miosis

A

Pinpoint pupils

63
Q

Define ptosis

A

Drooping upper lid

64
Q

Define diplopia

A

Double vision

65
Q

Define nystagmus

A

Cyclic movement of the eyeballs

66
Q

Define Diaphoresis

A

Excessive sweating

67
Q

What the Prescence of cyanosis represent

A

Tissue oxygenation is less than optimum.

68
Q

Inspection and palpation of the neck are of value in determining the:

A

Tracheal position
Jugular venous pressure(JVP)
Accessory muscle
Tracheal shift
Away from affected side
Tension pneumothorax
Pleural effusion
To the affected side: Atelectasis and lung resection

69
Q

What is the most common cause of JVP

A

Right heart failure

70
Q

What can cause JVP

A

Hypervolemia
Obstruction of venous return to the R atrium

71
Q

What’s the name that describes enlarged lymph nodes

A

Lymphademopathy

72
Q

Lymphademopathy is a common finding in patients with

A

Respiratory infections

73
Q

Tracheal bifurcation at carina is approximately

A

T4

74
Q

The diaphragm on the right dome gets to

A

Anterior: 5th rib
Posterior: T9

75
Q

The diaphragm on the left dome gets to

A

Anterior: 6th rib
Posterior: T10

76
Q

Superiorly on the anterior chest, the lungs extend ——-above the medial 3rd of the clavicles.
HINT: in cm

A

2-4cm

77
Q

Inferiorly, the lung borders extend to the——–midclavicular line and laterally ——-
HINT: Ribs

A

6th rib
8th rib

78
Q

Barrel chest is common in pts with what disease

A

Emphysema( COPD)

79
Q

Define barrel chest

A

abnormal increase in AP diameter

80
Q

Define pectus excavatum

A

Depression of part or all of the sternum

81
Q

Define pectus carinatum

A

Outward sternal protrusion anteriorly

82
Q

Define kyphosis

A

Spinal deformity in which the spine has an abnormal anteroposterior curvature

83
Q

Define scoliosis

A

Spinal deformity in which the spine has a lateral curvature

84
Q

Define kyphoscoliosis

A

Combination of kyphosis and scoliosis

85
Q

This is the paradoxical motion of the affected rib cage

A

Flail chest

86
Q

If a pt has flail chest what happens to their chest wall when they inhale or exhale

A

During inhalation: It sinks in
During expiration: there is an outward protrusion of the chest

87
Q

Define Tachypnea

A

Rapid rate of breathing

88
Q

Define Apnea

A

No breathing

89
Q

Define Biot

A

Irregular breathing with long periods of apnea

90
Q

Irregular type of breathing, breaths increase and decrease in depth and rate with periods of apnea

A

Cheyne stokes

91
Q

What is defined as deep and fast

A

Kussmaul

92
Q

Define apneustic

A

Prolonged inhalation

93
Q

Define Paradoxic

A

Injured portion of chest wall area moves in the opposite direction to the rest of the chest

94
Q

Define Abdominal paradox

A

Contraction of accessory muscles to aid inspiratory effort; diaphragm is pulled upwards and abdomen sinks inward during inspiration

95
Q

Define retractions

A

Inward movement of skin

96
Q

Examples of acute obstruction of intrathoracic airways

A

Asthma
Prolonged expiratory time

97
Q

Examples of acute upper airway obstruction

A

Croup
Prolonged inspiratory time

98
Q

Define vocal fremitus

A

Vibrations created by the vocal cords during talking

99
Q

Define tactile fremitus

A

When vibrations are heard on the chest wall

100
Q

A reduced tactile fremitus is often present in patients who are

A

Obese and overly muscular

101
Q

What can cause increased tactile fremitus

A

Pneumonia
Lung tumor or mass
Atelectasis (with patent bronchiole)

102
Q

What can cause decreased tactile fremitus

A

Unilateral
Bronchial obstruction w/ mucous plugging or foreign object
Pneumothorax
Pleural effusion
Diffuse
COPD w/ hyperinflation
Muscular or obese chest wall

103
Q

Define Rhonchial fremitus

A

The passage of air thru airways contaminated with thick secretions may produce palpable variations

104
Q

Vocal fremitus is found in diseases such as

A

Pneumonia
Atelectasis

105
Q

What causes decreased vocal fremitus

A

Unilateral
Bronchial obstruction
Pneumothorax
Pleural effusion
Diffuse
COPD w/ hyperinflation
Muscular or obese chest wall
Rhonchial fremitus
Vibrations produced by passage of air thru thick secretions

106
Q

What type of BS does the bell detect

A

Low frequency sounds( light placement)

107
Q

What type of BS does the diaphragm detect

A

High frequency ( firm placement)

108
Q

What are the 4 lung sound characteristics

A

Pitch
Amplitude
Distinctive characteristics
Duration of inspiration vs expiration

109
Q

What’s the term for sound heard over the trachea

A

Tracheal

110
Q

What’s the term for sound heard over the parenchyma

A

Vesicular

111
Q

What’s the term for sound that has an expiratory component equal to inspiratory component

A

Harsh
bronchial
(have the same definition)

112
Q

What’s the term for abnormal movement of air in the lungs

A

Adventitious

113
Q

Digital clubbing is a sign of

A

Cardiopulmonary disease

114
Q

What makes up the composition of blood

A

WBC(leukocytes)
RBC(erythrocytes)
Platelets(thrombocytes)

115
Q

Capillary refill helps show

A

Good cardiac output and digital perfusion

116
Q

Plasma is used to create

A

Electrolytes
Clotting factors
Immunologic factors
Proteins
Lipids
Hormones

117
Q

All substances used by cells must be transported by

A

Plasma

118
Q

Define Serum

A

plasma w/ clotting factors removed

119
Q

What does CBC include

A

RBC and WBC

120
Q

Primary function of WBC

A

Help fight infection

121
Q

What makes up WBC

A

Neutrophils
Eosinophils
Basophils
Lymphocytes
Monocytes

122
Q

What does Granulocytes include

A

Neutrophils
Eosinophils
Basophils

123
Q

Where are neutrophils produced in and what are they also known as

A

Bone marrow
Polymorphonuclear leukocytes

124
Q

Immature neutrophils in the circulating blood are known as

A

Bands

125
Q

What are eosinophils involved in

A

Immune system regulation

126
Q

It is an important line of defense against foreign microorganisms and cells

A

Lymphocytes

127
Q

T cells are involved in

A

Cell-mediated injury

128
Q

B cells are involved in

A

Humoral immunity

129
Q

What is the main function of Monocytes

A

Phagocytosis

130
Q

One of body’s first response to infection and inflammation

A

Neutrophilia

131
Q

What is the primary cause of neutropenia

A

Bone marrow failure

132
Q

Penia means

A

Decrease

133
Q

Philia and cytosis means

A

Increase

134
Q

Eosinophilia is elevated in the Prescence of

A

Parastic infestation
Allergic states
Allergic asthma

135
Q

Associated with myeloproliferative neoplasms(MPNs)

A

Basophilia

136
Q

What causes lymphocytosis

A

HIV
Trauma

137
Q

What causes monocytosis

A

TB
Syphilis
Typhoid fever
Fungal infections

138
Q

RBC’s are produced in the

A

Bone marrow

139
Q

primary function for RBC

A

Carry O2

140
Q

Life span for RBC

A

120 days

141
Q

It is the protein that carries O2 to the tissues and carries CO2 from the tissues to the lungs

A

Hemoglobin (Hgb or Hb)

142
Q

Define Anemia

A

Reduction in RBC mass of the body

143
Q

What are the causes anemia

A

Blood loss
Deficiency in cell formation
Abnormal cell formation
Chronic disease and aging

Patient Evaluation (4 decks)

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