Exam 2 Full Overview Flashcards
The lowest superficial part of the heart, usually located at the fifth intercostal space
Apex
Absence of breathing
Apnea
Any variation from the normal rhythm of a heartbeat
Arrhythmia or dysrhythmia
Listening for sounds produced with the body, usually with a stethoscope
Auscultation
Period where no sound is heard
Auscultatory gap
Pertaining the the armpit
Axillary
The rate at which heat is produced when the body is at rest
Basal metabolic rate (BMR)
Respirations that are shallow for two or three breaths with a period of variable apnea
Biot respirations
Pulse that is less than 60 beats per minute
Bradycardia
Slow and shallow breathing
Bradypnea
The pulse rate multiplied by the stroke volume
Cardiac output
Respirations that gradually become more shallow and are followed by periods of apnea, with repetition of the pattern
Cheyne-Stokes respirations
Sensations of cold and shaking of the body
Chills
Temperature deep with the body
Core temperature
Abnormal, nonmusical sound heard on auscultation of the lungs during inspiration
Crackles or rales
Abrupt decline in fever
Crisis
Bluish discoloration or skin color changes, particularly around the mouth and in the nail beds, due to lack of oxygen
Cyanosis
Abatement of fever
Defervescence
The lower pressure exerted on the artery when the heart is at rest between contractions
Diastolic pressure
Difficult and labored breathing
Dyspnea
Normal, relaxed breathing pattern
Eupnea
Stage of fever in which the body temperature rises to the new set point established by the hypothalamus and remains there until there is a resolution of the cause of the fever
Febrile
Elevated temperature
Fever
Wet sounds heard when auscultating the lungs; formerly called rhonchi
Gurgle
Blood pressure elevated above the normal range
Hypertension
Above-normal body temperature
Hyperthermia
Pattern of breathing in which there is an increase in the rate and depth of breaths and carbon dioxide is “blown off”, causing the blood level of carbon dioxide to fall
Hyperventilation
Abnormally low blood pressure
Hypotension
Subnormal body temperature
Hypothermia
Decreased amount of oxygen in the bloodstream
Hypoxemia
State of insufficient oxygen in the blood
Hypoxia
Sounds that relate to the effect of arterial wall vibrations during auscultation of blood pressure
Korotkoff sounds
Respirations having an increased rate and depth with panting and long, grunting exhalations
Kussmaul respirations
Breakdown, disintegration; also reduction or abatement
Lysis
Cellular chemical reactions in the body
Metabolism
Fall in blood pressure associated with dizziness, syncope (fainting), and blurred vision, which occurs upon standing
Orthostatic hypotension or postural hypotension
Excess fluid volume
Overhydration
Device that measures oxygen in the blood
Oximeter
Measurement of oxygen
Oximetry
Feel
Palpate
Deficit between the apical and radial pulse when measured simultaneously
Pulse deficit
The difference between the systolic pressure and the diastolic pressure
Pulse pressure
Fever; when a body temperature rises above 100.2°F (38.0°C)
Pyrexia
Agents that cause fever
Pyrogens
The exchange of oxygen and carbon dioxide in the lungs and tissues, which is initiated by the act of breathing
Respiration
Condition of circulatory failure
Shock
Device used to indirectly measure blood pressure
Sphygmomanometer
Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Stertor
Device that augments sound
Stethoscope
Shrill, harsh sound on inspiration; caused by obstruction of the upper air passages, as occurs in croup or laryngitis
Stridor
The volume of blood pushed into the aorta per heartbeat
Stroke volume
The maximum pressure exerted on the artery during left ventricular contraction
Systolic pressure
Heart rate greater than 100 beats per minute
Tachycardia
Increased or rapid breathing
Tachypnea
Eardrum
Tympanic membrane
The signs of life, namely pulse, respiration, temperature, and blood pressure
Vital signs
High-pitched whistling sound of air forced past a partial obstruction, as found in asthma and emphysema
Wheeze
What are the five vital signs
Temperature, pulse, respirations, blood pressure, and pain level. Also oxygen saturation level
What causes fever
Increase in metabolism
What acts as a thermostat and controls body temperature by a feedback mechanism
Hypothalamus
Where is the hypothalamus located
Between the cerebral hemispheres
What are the organs of respiration
Nose, pharynx, larynx, trachea, bronchi, and lungs
The pressure exerted on the arterial wall
Blood pressure
What is the normal temperature range
97.5 - 99.5
Average- 98.6
What are the sites used for temperature
Oral, rectal, axilla, tympanic, temporal
What are factors that affect body temperature
Drugs, age, exercise, time of day, disease conditions, emotional stress, environmental temperature, menstrual cycle and pregnancy
What are the fever patterns
Constant, intermittent, remittent, and relapsing
Temperature is continuously elevated, less than 1 degree variation within 24hrs
Constant
Temperature alternates rising and falling
Intermittent
High temperature falls, but never to normal, and rises again later in the day
Remittent
Temperature falls to normal and rises again in a repeating pattern
Relasping
Where is the oral thermometer placed
Posterior sublingual pocket on either side of the frenulum
Where are the pulse points
Radial, temporal, carotid, femoral, apical, popliteal, posterior tibial, dorsalis pedis
What is the normal pulse rate
60 - 100 bpm
Even beats with poor force, 1+
Weak and regular
Even beats with moderate force, 2+
Strong and regular
Even beats with strong force, 3+
Full and bounding
Barely palpable
Feeble
nonregular strong and weak beats occurring within 1 minute
Irregular
Weak and irregular
Thready
Absent
No pulse
What is the normal blood oxygen range
92 - 100%
What is the average blood pressure
120/80 mmHg
Systolic pressure indicated by faint, clear tapping sounds that gradually grow louder
Phase I Tapping
Silence as the cuff deflates for 30 to 40 mmHg
Auscultatory Gap- No Sound
Murmur that increases as the cuff is deflated
Phase II Swishing
Louder knocking sound that occurs with each heartbeat
Phase III Knocking
A sudden change or muffling of the sound
Phase IV Muffling
Disappearance of sound
Phase V Silence
Abnormal lung sounds elicited upon auscultation of the lungs during assessment
Adventitious sounds
Listening for sounds produced within the body, usually with a stethoscope
Auscultation
Lung sounds heard over the central chest or back
Bronchiovesicular sounds
Imaging technique used to quantify density
Dual-energy x-ray absorptiometry (DXA)
Fluid in interstitial spaces; swelling
Edema
Increased curve in the thoracic spine
Kyphosis
Damaged tissue
Lession
Exaggerated lumbar curve
Lordosis
Involuntary, rapid, rhythmic movement of the eyeball
Nystagmus
Smelling
Olfaction
Touching with the hands and fingers
Palpation
Light, quick tapping on the body surface to produce sounds
Percussion
Pronounced lateral curvature of the spine
Scoliosis
Involuntary fine movement of the body or limbs
Tremors
Elastic condition of skin
Turgor
Soft, rustling sounds heard in the periphery of the lung fields
Vesicular sounds
Condition of being without oxygen
Anoxia
Absence of breathing
Apnea
Collapsed or airless part of the lung; collapse of alveoli
Atelectasis
Tube for insertion into a duct or cavity
Cannula
Bluish discoloration or skin color changes, particularly around the mouth and in the nail beds, due to lack of oxygen
Cyanosis
Difficult and labored breathing
Dyspnea
Within the trachea
Endotracheal
Cough up or spit out
Expectorate
Movement of air out of the lungs
Expiration
Device that supplies moisture to a gas
Humidifier
Excess carbondioxide in the blood
Hypercapnia
Decreased amount of oxygen in the bloodstream
Hypoxemia
State of insufficient oxygen in the blood
Hypoxia
Movement of air into the lungs
Inspiration
Device that dispenses liquid in a fine spray, used in inhalation therapy
Nebulizer
Curved guide that is inserted into the trachea to facilitate placement of a tube
Obturator
Inward movement of respiratory muscles upon inspiration
Retraction
Increased or rapid breathing
Tachypnea
Adhesive, sticky
Tenacious
Opening into the trachea
Tracheostomy
Illness that results when most or all of the body is exposed to a high dose of radiation, usually over a short period of time
Acute radiation sickness (ARS)
The phenomenon of nurses becoming desensitized to patient care alarms and missing or delaying their response to the alarm
Alarm fatigue
Biologic agent or condition that can be harmful to a persons health
Biohazard
The release of pathogenic microorganisms into a community to achieve political and/or military goals
Bioterrorism
The total of all elements and conditions that surround us and influence our development
Environment
The amount of moisture in the air
Humidity
Substance that, when ingested, inhaled, absorbed, applied, injected, or developed withing the body, may cause functional or structural disturbances
Poison
Any objective evidence of disease or dysfunction; perceived by doctor
Sign
Any indication of disease perceived by the patient; subjective
Symptom
Part of the stethoscope that detects high pitched sounds
Diaphragm
Part of the stethoscope that detects low pitched sounds
Bell
Where is the apical pulse found
Left midclavicular between the 3rd and 5th intercostal space
Grating or scratchy sound heard in the lungs
Pleural friction rub
Air sacs
Alveoli
What are the structures of respiration
Nose, mouth, pharynx, larynx, trachea
What is the most common cause of respiratory insufficiency
Airway obstruction
How is hypoxia treated
Administering oxygen and correcting the cause
What is the simplest method of clearing air passages
An effective cough
What technique is used for nasopharyngeal suctioning
Aseptic
What technique is used for tracheobronchial suctioning
Sterile
Circumscribed, flat area with a change in skin color
Macule
Elevated, solid lesion
Papule
Circumscribed, superficial collection of serous fluid
Vesicle
Circumscribed, elevated, superficial, solid lesion
Plaque
Firm, edematous, irregularly shaped area
Wheal
Elevates, superficial lesion filled with purulent fluid
Pustule
How is the pulse rate measured
Placing two or three fingers over a superficial artery that has a bone behind it
How is an infants temperature taken
Rectally
Tachycardia refers to a pulse that is
Greater than 100 beats per minute
What type of respiration describes fast, deep breathing
Kussmauls
What do cardiac contractions produce
Pulse
What is the first step in physical assessment (data collection)
Observing the patients behavior and appearance
When should blood pressure be measured
After the patient has been sitting or lying down for 5 minutes
Softs, rustling sounds normally heard in the periphery of the lung fields that are longer during inspiration that expiration
Vesicular sounds
The patients abdomen is assessed when the patient is in what position
Supine
What assessment is performed at regular intervals on patients who have experienced head trauma or who have had brain surgery
Neurologic check
What tool can be used to examine canals, including the nasal and vaginal canals
Speculum
What technique is performed with the hands and uses touch to feel various body parts during physical examination
Palpation
The pronounced lateral curvature of the spine
Scoliosis
A croaking sound heard where there is a partial obstruction of the upper air passages in the lungs
Stridor
What are the primary organs of the respiratory system
Lungs, bronchus, trachea
The decreased amount of oxygen in the bloodstream resulting from respiratory insufficiency
Hypoxemia
What process are inspiration and expiration phases of
Respiration
What are patients who have undergone abdominal or chest surgery are at risk for
Pneumonitis
Nasopharyngeal suctioning is designed to remove what from the upper respiratory tract
Accumulated secretions
What is a surgical incision into the trachea to aerate the lungs
Tracheostomy
What is the most common cause of respiratory insufficiency
Obstruction
The function of the respiratory system is to supply what to the bloodstream
Oxygen
The purpose of a tracheostomy is to remove obstruction and ease what
Breathing
Average room temperature for an adult patients would ideally be between
68 and 74 degrees F
If no laundry hamper is available, the next best place for soiled linens is where
A pillowcase
The release of pathogenic or hazardous substances with the aim to harm humans is known as
Bioterrorism
What is the acronym for a fire emergency
RACE
How often must the nurse remove a patients protective device and change the patients position
Every 2 hours
What are patients entering the emergency room triaged based on
Type of care required
What are common factors of falls
Impaired physical mobility, altered mental status, sensory and/or motor deficits
What put a patient at high risk for burns
Diabetes, impaired circulation, paralysis, decreased mental awareness
What some preventions for burns
Barrier between patients skin and thermal application, check temperature of oral liquids, warn patient if a drink or food is hot, caution patient to not lay or sleep with heating pads or ice packs, inspect electrical cords for frayed or broken areas that may cause fire
What is the acronym PASS
Pull, Aim, Squeeze, Sweep
What is the acronym RACE
Rescue, Activate Alarm, Contain, Extinguish or Evacuate
What is OSHA
Occupational Safety and Hazard Association
What is SDS and why is it used
Safety Data Sheet; consulted for recommended methods of storage, labeling, handling spills, and disposal of biohazards
What do you report to the poison control center
Name of the products, patients age, weight, pertinent medical history, amount and timing of products involved, exposure route of product, any symptom and /or complaints
What can restricting movement on a long-term basis lead to
muscle weakness, atrophy, loss of bone mass, joint contractures, constipation, incontinence, pressure injuries, depression, cognitive impairment
Behavioral indications
Psychiatric setting
Non-behavioral indications
Medical setting
