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Nursing School > Exam 2: NR414 Rev 2 > Flashcards

Exam 2: NR414 Rev 2 Flashcards

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1
Q

This is a term for “dry mouth”

A

Xerostomia

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2
Q

Another name for nosebleed

A

Epistaxis

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3
Q

Jarvis:

The second heart sound is the result of:

A

closing of the mitral and tricuspid valves

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4
Q

Jarvis:

When palpating an apical impulse what is the normal size?

A

2 cm

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5
Q

Jarvis:

Where do you listen in the pulmonic valve area?

A

the 2nd Left Interspace

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6
Q

Jarvis:

What is the difference between S2 & S3?

A

S3 is lower pitched and is heard at the apex

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7
Q

Jarvis:

When auscultating the heart your first step is to:

A

identify S1 & S2

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8
Q

Jarvis:

Where is a split S2 heard most clearly?

A

pulmonic

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9
Q

The most common site of nosebleeds

A

Kiesselbach Plexus

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10
Q

What is a common cause of dry mouth?

A

medications

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11
Q

Which side of the lungs is narrower and only has 2 sides

A

Left lung

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12
Q

This breath sound is moderate in pitch, inspiration= expiration

A

Bronchovesicular breath sounds

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13
Q

Where is the left lateral lung located?

A
  • sixth rib, midclavicular line
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14
Q

Where is the Right Lateral Lung Border?

A

Fifth intercostal

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15
Q

Where is the posterior apex of the lung border?

A

C7

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16
Q

Bronchial Tracheal Characteristics:

A
  • High pitched
  • Inspiration < Experiation
  • Harsh,Hollow, Tubular
  • Trachea/Larynx
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17
Q

This breath sound is over the major bronchi where fewer alveoli are located: Posterior b/w capulae especially on Rt anterior. Around Upper sternum in 1st and 2nd ICS

A

Bronchovesicular

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18
Q

This breath sound is over peripheral lung fields where air flows through smaller bronchioles and alveoli

A

Vesicular

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19
Q

Characteristics of Vesicular Sounds

A
  • Low pitch
  • inspiration > Expiration
  • Rustling like wind in trees
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20
Q

This is purposeful and expands the alveoli. May indicate emotional dysfunction and could lead to hyperventilation.

A

Sigh

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21
Q

Name this respiration pattern

A

Biot’s Respiration

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22
Q

This is a series of normal respiration followed by a period of apnea. Cycle is variable, lasting from 10- 60 sec.

A
  • Biots Respiration (irregular)
  • Seen with head trauma, brain abscess, heat stroke spinal meningitis, & encephalitis
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23
Q

Name this respiration pattern?

A

Normal Adult

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24
Q

Rate is usually 10-20 breaths/min. Depth 500-800ml. Pattern is even.

A

Normal Adult

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25
Q

Name this respiration pattern?

A

Cheyne Stokes

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26
Q

Breathing periods last 30-45 sec, with 20 sec periods of apnea. Respirations wax and wane.

A
  • Cheyne Stokes
  • severe heart failure, drug OD, older adult during sleep, infant
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27
Q

Name this respiration pattern

A

Tachypnea

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29
Q

Rapid shallow breathing. >24/min.

A
  • Tachypnea
  • exercise, fever, fear, pneumonia
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30
Q

Name this respiration pattern

A

Bradypnea

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31
Q

Slow breathing,

A
  • Bradypnea
  • drug induced
  • diabetic coma
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32
Q

Name this respiration pattern

A

hyperventilation

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33
Q

Rate & depth both increase with this respiration type. Blows off CO2 causing a low level in the blood.

A
  • Hyperventilation
  • extreme exertion, fear, anxiety, hepatic coma, diabetic, lesions of the brain
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34
Q

Name this respiration pattern

A

Chronic Obstructive Breathing

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35
Q

This is when you have prolonged expiration to overcome airway resistance.

A
  • Chronic Obstructive Breathing
  • can cause air trapping (dyspneic episode)
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36
Q

Name this respiration pattern

A

Hypoventilation

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37
Q

An irregular shallow pattern of breathing caused by an OD of narcotics, anesthetics or prolonged bed rest.

A
  • Hypoventilation
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38
Q

Name this adventitious sound pattern

A

Stridor

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39
Q

This sound is high pitched, monphonic. It is louder in the neck than over the chest wall. Upper airway obstruction- swollen tissues or lodged foreign body.

A
  • Stridor
  • croup, acute epiglottis child, foreign inhalation.
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40
Q

Name this adventitious sound pattern

A
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41
Q

Name this adventitious inhalation pattern

A

Wheeze high pitched (sibilant

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42
Q

This is a high pitched musical squeaking/polyphonic. Predominantly in expiration. Sounds are similar to a vibrating reed. Passageways narrowed almost to closure.

A
  • Wheeze high, Sibilant
  • airway obstruction, chronic emphysema
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43
Q

Name this adventitious sound

A

Crackles fine

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44
Q

This is a high pitched short crackling w/ popping sounds. Heard during inspiration. Cough does NOT clear it

A
  • Crackles Fine
  • pneumonia, heart failure, i.fibrosis, c.bronchitis, asthma
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45
Q

Name this adventitious sound pattern

A

Atelactic Crackles

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46
Q

This is a loud low pitched bubbling & gurgling. Starts in early inspiration. Sounds like a velcro fastener. Inhaled air is colliding with secretions in the trachea and large bronchi.

A
  • Crackles Course
  • pulmonary edema, pneumonia, depressed cough reflex
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47
Q

This sounds like fine crackles but do not LAST. They are not pathologic. It is when section of alveoli do not aerate. Deflate and accumulate secretions.

A
  • Atelactic Crackles (rales)
  • bedridden pateint
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48
Q

Name this adventitious sound pattern?

A

Pleural Friction Rub

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49
Q

This is a very superficial sound that is course and low. Like 2 pieces of leather are being rubbed together. Loss of lubricating fluid. Heard best in anterolateral wall.

A
  • Pleural Friction Rub
  • painful to breathe
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50
Q

Name this adventitious sound pattern

A

Wheeze Low pitch (sonorous ronchi)

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51
Q

You will hear a single note. Snoaring or moaning sounds. May clear a little by coughing. It is caused by airflow obstruction.

A
  • Wheeze low pitched (sonorous)
  • bronchitis, airway ob tumor
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52
Q

Characteristics of S1

A
  • First heart sound
  • Closure of the AV valves
  • “Lub”
  • heard best at the apex
  • Beginning of systole
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53
Q

Characteristics of S2

A
  • Second heart sound
  • closure of semilunar valves
  • “Dub”
  • End of Systole
  • heart at Base of heart
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54
Q

Where is S1 louder than S2

A

at the apex

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55
Q

Which artery does S1 coincide with?

A

carotid

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56
Q

Which wave does S1 coincide with on ECG?

A

R-wave

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57
Q

Characteristics of S3

A
  • Vibrations from filling ventricles
  • “lub-dubba” “kentucky”
  • Early diastole, after S2
  • At apex with bell
  • left lateral position
58
Q

Characteristics of S4

A
  • Blood being pushed into a noncompliant ventricle
  • “da-lub-dub” “Tennessee”
  • End of diastole, presystole, before S1
  • Heard at apex with bell
59
Q

Characteristics of a Murmur

A
  • Turbulent blood flow and collision currents
  • “swooshing”
  • structural defects in valves, unusual opening in chambers, anemia.
  • Heard best at Chest Wall
60
Q

What data are you gathering during Auscultation of Heart Sounds x5

A
  1. Rate / Rhythm
  2. Identify S1 & S2 (together)
  3. S1 & S2 (separate)
  4. S3 & S4
  5. Murmurs
61
Q

What are you listening for with murmurs?

A
  • Timing
  • Loudness
  • Ptich
  • Pattern
  • Quality
  • Location
  • Radiation
  • Posture/Position
62
Q

All Patients Take Meds..

A
  • Aortic (2nd Rt, ICS)
  • Pulmonary (2nd Left, ICS)
  • Tricuspid (Lt lower sternum)
  • Mitral (5th ICS midclavical)
63
Q

Step 1: Blood has cicrulationg through the body, lost its oxygen and collected CO2, where does it enter?

A
  • Right Atrium of the heart through the Vena Cava
64
Q

Step 2: Right Atrium Contracts and pumps blood through which valves?

A

Tricuspid valve and right ventricle

65
Q

Step 3 of 9: The Right Ventricle pumps blood where?

A
  • Through the pulmonary artery into the lungs
66
Q

Step 4: What do the tiny blood vessels (capillaries) in the lungs do?

A

absorb CO2 from blood and replace it with oxygen

67
Q

Step 5: oxygenated blood flows through the pulmonary vein and into where?

A
  • Left Atrium
68
Q

Step 6: Oxygenated blood pumps throu the mitral valve and into where?

A

Left Ventricle

69
Q

Once the blood has gone through the aortic arch, what are the option for where blood can be pumped?

A
  • thru carotid artery into the brain
  • auxiliary arteries into the arms
  • aorta and into the torso/legs
70
Q

Step 8: Blood moves through the arteries, then through capillaries, where does it return?

A

Veins

71
Q

Step 9: What is the last step of the cardiac cycle?

A

Deoxygenated blood will return to the heart

72
Q

this pumps blood to pulmonary circulation

A

right ventricle

73
Q

pumps blood to the systemic circulation

A

left ventricle

74
Q

this is a valve between LA & LV

A

Mitral Valve

75
Q

Valve betwee RV & Pulmonary Aorta

A

pulmonic valve

76
Q

This drains arms

A

subclavian vein

77
Q

Organ in LUQ of the adomen that produces lymphocytes and monocytes

A

spleen

78
Q

What is valsavle maneuver?

A
  • bearing down
  • lead to herniated disc
  • tumor
79
Q

This is a palpable vibration while patient says “blue moon”

A

fremitus

80
Q

Where do sounds for tactile fremitus originate?

A
  • Generated from larynx > patent bronchi > lung parenchyma > chest wall (where you feel them)
81
Q

Unequal chest expansion occurs with x4

A
  1. marked atelectasis;
  2. pneumonia;
  3. thoracic trauma;
  4. pneumothorax
82
Q

This is soft, muffled thud; signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis or tumor

A

Dull

83
Q

When does the apical impulse increase in size and duration?

A
  • anxiety,
  • fever,
  • hyperthyroidism
  • anemia
84
Q

this is felt over the precordium during systole in aortic stenosis, pulmonary stenosis, and ventricular septal defect.

A

systolic thrill

85
Q

This is when ventricular filling creates vibrations

A

S3

86
Q

Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention Enema by doing which of the following?

A) Administering a large volume solution 500 to 1000 ml
B) Mixing milk and molasses and equal parts for an enema
C) Instructing the patient to retain the enema for at least 30 seconds
D) Administering the enema while the patient is sitting on a toilet

A

c) Instructing the patient to retain the enema for at least 30 sec

87
Q

During removal of a fecal impaction, which of the following could occur Because of vaginal stimulation?
A) Bradycardia
B)Atelectasid
C) Tachycardia
D) Cardiac tamponade

A

A) Bradycardia

Removing a fecal impaction manually may result in stimulation of the vaginal nerve and resulting bradycardia

88
Q

What is the incidence of deep vein thrombosis?

A

Age-dependent
In a 50yo: 1/1,000 per year
Young adults: 1/10,000 per year
In elderly: 1/100 per year

89
Q

What are the signs and symptoms of DVT?

A
  • Distension of surface veins,
  • pain/tenderness,
  • redness/discolouration,
  • swelling,
  • warmth
90
Q

What are subjective assessment questions for Cardiac x8

A
  • chest pain
  • cough
  • shortness of breath
  • swelling in feet or legs
  • facial skin color
  • fatigued
  • family history of heart disease
  • use more than one pillow
91
Q

This is a condition in which one or more areas of your lungs collapse or don’t inflate properly.

A

Atelactic

92
Q

Pathological Reasons for Listening for S3

A

Anemia,
sign of HF
Volume overload
hyperthyroidism
pregnancy
renal failure
persists when sitting up

93
Q

Reasons for listenting for S4

A

decreased compliance of ventricle
systolic overload
aortic stenosis
systemic hypertension

94
Q

What are reasons for having a murmur

A

During menstrual cycle (benign)
During Exercise
Thyroid level too high
Anemia (low blood)-less rbcs, less oxygen
expected for infants
structural defects in valve
unusual openings in chambers

95
Q

What happens heart/neck when Aging?

A

BP increases
lifestyles
sodium
Left ventricle increases
Increase Arrhythmias
Orthostatic Hypotension (getting out of bed fast)
check for bruits in carotid
systolic heart murmur

96
Q

Where do you assess an adult heart

A

5th ICS

97
Q

Where do you assess infant heart?

A

3-4 ICS

98
Q

High risk factors for heart disease

A

high blood pressure
smoking
high cholesterol
diabetes
obesity

99
Q

Intraluminal valves help to ensure

A

blood moves towards the heart

100
Q

What do varicose veins look like?

A

blue
torturous
you can fee

101
Q

How would the skin present itself if you had arterial insufficiencies?

A

thin, shiny skin, thick nails
less hair on legs

102
Q

Which lung lobe is shorter?

A

the right side, because of the liver

103
Q

What is visceral pleura

A

sack for the lungs

104
Q

What does negative pressure mean referring to the lungs

A

lungs are being pulled open, otherwise lungs would collapse

105
Q

Where does gas exchange occur?

A

bronchial trees

106
Q

What is Hypercapnea

A

too much CO2

107
Q

Is expiration passive or active?

A

Passive

108
Q

What are discontinuous sounds?

A
  • crackles
  • atelectic crackles
  • pleural friction rub
109
Q

What are continuous sounds

A

wheeze, stridor

110
Q

What do stretch receptors initiate

A

contraction of sigmoid colon/rectal muscles

111
Q

What can accompany a murmur?

A

a thrill

112
Q

What does a thrill signify?

A

stenosis or hypertension

113
Q

What is a heave or lift?

A

sustained forceful thrusting of ventricle during systole

114
Q

Where can a right heave be seen

A

sternal border

115
Q

Where is a left heave seen?

A

at the apex

116
Q

What can a bruit indicate?

A

hyperplasia of the thyroid,

117
Q

Characteristics of Split S2

A
  • happens during inspiration but NOT while holding breath
  • in the pulmonic area
118
Q

Cardiac assessment for infant (subj)

A
  • mother during prego
  • cyanosis
  • growth as expected?
  • play w/o tiring?
  • naps per day, how long?
119
Q

Cardiac assessment for child (subj)

A
  • growth as expected?
  • keeping up?
  • rest during play?
  • joint pain
  • headaches/nosebleeds
  • respiratory infection
  • siblings w/ defects
120
Q

Where do you assess pulses?

A
  • Temporal Artery
  • Carotid Artery
  • Brachial/Ulnar/Radial
  • Legs
121
Q

What is the difference for children vs adults with lymph nodes?

A
  • enlarge in children
  • atrophy in adults
122
Q

What is the function of lymphatics

A

retrieve excess fluid from tissue spaces and return to bloodstream

123
Q

What does Venous Insufficiency look like?

A
  • wet
  • darker skin pigmentation
124
Q

What does Arterial Insufficiency look like?

A
  • light color
  • dry
  • leg cramping
125
Q

Difficulty swallowing

A

dysphasia

126
Q

What are systemic changes with decreased oxygen?

A
  1. clubbing
  2. hair loss
  3. hypoxic
  4. hypoxemia
127
Q

What is WOB

A
  • work of breathing
128
Q

What do you inspect for the lungs?

A
  • shape, AP:T Ratio
  • Nails
  • Position
  • WOB
  • Skin Color
129
Q

What causes decrease breath sounds?

A

COPD & mucous

130
Q

What causes increased breath sounds

A

pneumonia

131
Q

What position do you place patient for an enema

A

left lying lateral

132
Q

How much fluid can an average adult handle for an enema?

A
  • 350-500 ML
133
Q

Characteristics of Small Intestine

A
  • absorption of nutrients and electrolytes
  • 20’ long
134
Q

Name the 3 sections of the small intestine

A
  1. Duodenum
  2. Jejunum
  3. Ileum
135
Q

Name the characteristics of the large intestine

A
  • 5-6 ft long
  • Elimination
  • absorbs water/electrolytes
136
Q

Name the 4 sections of the large intestine

A
  1. ascending
  2. transverse
  3. descending
  4. sigmoid
137
Q

What does the midsection of the thoracic cavity contain?

A
  • Esophagus
  • Trachea
  • Heart
  • Great vessels
138
Q

The nurse recognizes that the administration of a drug influences cell physiology. What is the term for this concept?

A

Pharmacodynamics

139
Q

the study of what the body does to the drug

A

Pharmacokinetics

Nursing School (33 decks)

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