Exam 2: NR414 REV Flashcards
This is grinding of the teeth expecially at night
Bruxism
Smooth Glossy tongue that occurs with pernicious anemia
Atrophic Glossitis
This is a fungal infections, commonly called thrush in new borns
Candidiasis
This is a term for “dry mouth”
Xerostomia
A tumor caused by infection with human herpesvirus. It is the most common lesion seen in people wit AIDS
Kaposi’s Sarcoma
This is a fungal infection of the tongue. A temporary, harmless oral condition that gives your tongue a dark, furry appearance.
Black hairy tongue
Crcking erythema and painful fissures at the corners of the mouth that occur with excess salivation.
Cheilitis
Smooth, pale gray nodules that are overgrowths of mucosa.
Polyps
Another name for nosebleed
Epistaxis
Another name for runny nose
Rhinorrhea
a nontender, fibrous nodule in the gum between teeth
Epulis
painless enlargement of the gums, sometimes overreaching the teeth.
Gingival hyperplasia
Gum margins are red, swollen, and bleed easily, usually due to poor hygeine or vitamin C deficiency
Gingivitis
Another name for a canker sore. (painful, open sore in the mouth. Canker sores are white or yellow and surrounded by a bright red area.)
Aphthous Ulcers
Another name for cold sores
Herpes Simplex 1
decrease mobility of the tongue tip
Ankyloglossia
Chalky, white, thick, raised patch with well defined borders.
Leukoplasia
Jarvis:
How does atrial systole occur?
independently of ventricular function
Jarvis:
The second heart sound is the result of:
closing of the mitral and tricuspid valves
Jarvis:
When palpating an apical impulse what is the normal size?
2 cm
Jarvis:
Where do you listen in the pulmonic valve area?
the 2nd Left Interspace
Jarvis:
What is the difference between S2 & S3?
S3 is lower pitched and is heard at the apex
Jarvis:
When auscultating the heart your first step is to:
identify S1 & S2
Jarvis:
Where is a split S2 heard most clearly?
pulmonic
Jarvis:
Why is the stethoscope placed lighting against the skin?
it does not act as a diaphragm
Jarvis:
What is the function of the venous system?
Hold more blood when blood volume increases
Jarvis:
What organs aid the lymphatic system?
spleen, tonsils, thymus
Jarvis:
What causes varicose veins in pregnant women?
pressure of the growing uterus on the veins
Jarvis:
A 4+ edema of the right leg is documents. The best description of theis type of edema is:
very deep pitting, indentation lasts a long time
Jarvis:
A known risk for venous ulcer development is:
obesity
Jarvis:
What does Brawny mean?
non pitting edema
The most common site of nosebleeds
Kiesselbach Plexus
Which sinuses can we physically examine
Frontal, Maxillary
This is the midline fold of tissue that connects the gongue to the floor of the mouth
Frenulum
Where are the largest salivary glands located?
Within the cheeks in front of the ear
What is a common cause of dry mouth?
medications
the bone and cartilage that divide the nasal cavity of the nose in half – is significantly off center, or crooked, making breathing difficult
Deviated Septum. Document in case patient needs to be suctions
Where is the most common locations for oral malignancies to occur
under the tongue. “Mucosal Gutter”
In a medical reocord, the tonisl are grades as 3+. The tonsils would be located where?
touching the uvula
What is the function of the nasal turbinates?
Warm the inhaled air
The opening of an adult’s partodi gland (Stenson’s Duct) is opposite the:
upper 2nd molar
How can you tell the difference between a nasal polyp and a nasal turbinate?
- A polyp is:
- movable
- pale and gray in color
- nontender
What are epistein pearls?
- small round, white shiny papules on the hard palate and gums of 2 month old.
What should you palpate when examiniong the tongue
the U shaped area under the tongue
What is the manubriosternal angle
the articulation of the manubrium and the body of the sternum
Which side of the lungs is narrower and only has 2 sides
Left lung
What are signs of chronic bronchitis?
- cough for at least 3 months of the year
- 2 years in a row
Where do you asses for symmetric chest expansion
- place hands on posterolateral chest wall
- thums at the level of T9 or T10
- slide hands up to pinch up a small fold of skin
Absence of diaphtramatic excursion (breathing) occurs with…
Pleural effusion or atelectasis of the lower lobes
Where do you auscultate for breath sounds
- hold diaphragm of steh against chest wall
- listen to 1 full respiration in each location
- compare Side to Side
This breath sound is moderate in pitch, inspiration= expiration
Bronchovesicular breath sounds
What is the diagnosis:
Increase respiratory rate, chest expansion decreased on left side, dull percussion over left lower lobe. Breath sounds with crackles over left lobe.
Lobar Pneumonia
In a physical assessment what is a symptom of chronic congenital heart disease and COPD
- nail base >160 degrees
- base feels spongy to palpate
Patient complains of pain with breathing. You note low pitched sound during both inspiration and expiration.
Pleural Friction Rub
“99”, “Blue”, “EEEE”
egophony technique while moving stethoscope
This tool measures arterial oxygen saturation
pulse oximeter
Which assessment technique is best utilized for examing a pleural friction rub
auscultation
Where is the apex of the lung located?
- 3 to 4 cm above the inner third of the clavicels
Where is the base of the lung?
Rests on the diaphragm
Where is the left lateral lung located?
- sixth rib, midclavicular line
Where is the Right Lateral Lung Border?
Fifth intercostal
Where is the posterior apex of the lung border?
C7
How is a normal chest shaped?
elliptical shape with an anteroposterior transverse diameter. Ratio 1:2
Anteroposterior means
How is a barrell chest shaped
Anteroposterior = transverse diameter
How is pectus excavatum shaped?
sunken sternum and ajacent cartilages
How is pectus carniatum shaped?
forward protrusion of the sternum with ribs sloping back at either side
How is scoliosis shaped?
lateral S shaped Curvature of the thoracic and lumbar spine
Exaggerated posterior curvature of the spine
Kyphosis
Bronchial Tracheal Characteristics:
- High pitched
- Inspiration < Experiation
- Harsh,Hollow, Tubular
- Trachea/Larynx
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
Bronchovesicular
This breath sound is over peripheral lung fields where air flows through smaller bronchioles and alveoli
Vesicular
Characteristics of Vesicular Sounds
- Low pitch
- inspiration > Expiration
- Rustling like wind in trees
What is the name for this respiration pattern?
Sigh
This is purposeful and expands the alveoli. May indicate emotional dysfunction and could lead to hyperventilation.
Sigh
Name this respiration pattern
Biot’s Respiration
This is a series of normal respiration followed by a period of apnea. Cycle is variable, lasting from 10- 60 sec.
- Biots Respiration (irregular)
- Seen with head trauma, brain abscess, heat stroke spinal meningitis, & encephalitis
Name this respiration pattern?
Normal Adult
Rate is usually 10-20 breaths/min. Depth 500-800ml. Pattern is even.
Normal Adult
Name this respiration pattern?
Cheyne Stokes
Breathing periods last 30-45 sec, with 20 sec periods of apnea. Respirations wax and wane.
- Cheyne Stokes
- severe heart failure, drug OD, older adult during sleep, infant
Name this respiration pattern
Tachypnea
Rapid shallow breathing. >24/min.
- Tachypnea
- exercise, fever, fear, pneumonia
Name this respiration pattern
Bradypnea
Slow breathing, <10/min
- Bradypnea
- drug induced
- diabetic coma
Name this respiration pattern
hyperventilation
Rate & depth both increase with this respiration type. Blows off CO2 causing a low level in the blood.
- Hyperventilation
- extreme exertion, fear, anxiety, hepatic coma, diabetic, lesions of the brain
Name this respiration pattern
Chronic Obstructive Breathing
This is when you have prolonged expiration to overcome airway resistance.
- Chronic Obstructive Breathing
- can cause air trapping (dyspneic episode)
Name this respiration pattern
Hypoventilation
An irregular shallow pattern of breathing caused by an OD of narcotics, anesthetics or prolonged bed rest.
- Hypoventilation
What does adventitious sounds mean?
Abnormal
Name this adventitious sound pattern
Stridor
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.
- Stridor
- croup, acute epiglottis child, foreign inhalation.
Name this adventitious sound pattern
Name this adventitious inhalation pattern
Wheeze high pitched (sibilant
This is a high pitched musical squeaking/polyphonic. Predominantly in expiration. Sounds are similar to a vibrating reed. Passageways narrowed almost to closure.
- Wheeze high, Sibilant
- airway obstruction, chronic emphysema
Name this adventitious sound
Crackles fine
This is a high pitched short crackling w/ popping sounds. Heard during inspiration. Cough does NOT clear it
- Crackles Fine
- pneumonia, heart failure, i.fibrosis, c.bronchitis, asthma
Name this adventitious sound pattern
Atelactic Crackles
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.
- Crackles Course
- pulmonary edema, pneumonia, depressed cough reflex
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.
- Atelactic Crackles (rales)
- bedridden pateint
Name this adventitious sound pattern?
Pleural Friction Rub
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.
- Pleural Friction Rub
- painful to breathe
Name this adventitious sound pattern
Wheeze Low pitch (sonorous ronchi)
You will hear a single note. Snoaring or moaning sounds. May clear a little by coughing. It is caused by airflow obstruction.
- Wheeze low pitched (sonorous)
- bronchitis, airway ob tumor
Characteristics of S1
- First heart sound
- Closure of the AV valves
- “Lub”
- heard best at the apex
- Beginning of systole
Characteristics of S2
- Second heart sound
- closure of semilunar valves
- “Dub”
- End of Systole
- heart at Base of heart
Where is S1 louder than S2
at the apex
Which artery does S1 coincide with?
carotid
Which wave does S1 coincide with on ECG?
R-wave
Characteristics of S3
- Vibrations from filling ventricles
- “lub-dubba” “kentucky”
- Early diastole, after S2
- At apex with bell
- left lateral position
Characteristics of S4
- Blood being pushed into a noncompliant ventricle
- “da-lub-dub” “Tennessee”
- End of diastole, presystole, before S1
- Heard at apex with bell
Characteristics of a Murmur
- Turbulent blood flow and collision currents
- “swooshing”
- structural defects in valves, unusual opening in chambers, anemia.
- Heard best at Chest Wall
What data are you gathering during Auscultation of Heart Sounds x5
- Rate / Rhythm
- Identify S1 & S2 (together)
- S1 & S2 (separate)
- S3 & S4
- Murmurs
What is the formula for pulse deficit
apical rate - radial rate
What are you listening for with murmurs?
- Timing
- Loudness
- Ptich
- Pattern
- Quality
- Location
- Radiation
- Posture/Position
If you hear a swooshin sound during diastolic sounds, what does that indicate?
Heart Disease
All Patients Take Meds..
- Aortic (2nd Rt, ICS)
- Pulmonary (2nd Left, ICS)
- Tricuspid (Lt lower sternum)
- Mitral (5th ICS midclavical)
What are the 2 phases of the Cardiac Cycle?
- Diastole: relax, filling, Atrial Kick
- Systole: blood pumped out
Documenting Heart Sounds x4
- Frequency/Pitch
- Intensity/Loudness
- Duration
- Timing: systole/diastole
Step 1: Blood has cicrulationg through the body, lost its oxygen and collected CO2, where does it enter?
- Right Atrium of the heart through the Vena Cava
Step 2: Right Atrium Contracts and pumps blood through which valves?
Tricuspid valve and right ventricle
Step 3 of 9: The Right Ventricle pumps blood where?
- Through the pulmonary artery into the lungs
Step 4: What do the tiny blood vessels (capillaries) in the lungs do?
absorb CO2 from blood and replace it with oxygen
Step 5: oxygenated blood flows through the pulmonary vein and into where?
- Left Atrium
Step 6: Oxygenated blood pumps throu the mitral valve and into where?
Left Ventricle
Which side of the heart contracts the strongest?
the Left Side
Why does the left side contract the strongest?
- To send blood out the left ventricle and through the aortic arch and on its way to al parts of the body.
Once the blood has gone through the aortic arch, what are the option for where blood can be pumped?
- thru carotid artery into the brain
- auxiliary arteries into the arms
- aorta and into the torso/legs
Step 8: Blood moves through the arteries, then through capillaries, where does it return?
Veins
Step 9: What is the last step of the cardiac cycle?
Deoxygenated blood will return to the heart
Myocardium
Muscle layer of the heart
Smooth inner layer of the heart
Endocardium
Between parietal and visceral layer
pericardial space
This is the pacemaker of the heart with 60-100 bpm
sinoatrial node
Major vein of the head
- jugular
- drains the head
Major artery that supplies blood to the head
carotid
this pumps blood to pulmonary circulation
right ventricle
pumps blood to the systemic circulation
left ventricle
this is a valve between LA & LV
Mitral Valve
Valve betwee RV & Pulmonary Aorta
pulmonic valve
Paces Heart at 40-60 BPM
AV Node
This is lymphatic tissue found in the oropharynx
Tonsils
This drains arms
subclavian vein
Organ in LUQ of the adomen that produces lymphocytes and monocytes
spleen
These veins drain the legs
iliac
This is lyphatic tissue in thorax that helps w/ T-Cell differentiation
Thymus
What does the external sphincter do?
Relaxes
What is valsavle maneuver?
- bearing down
- lead to herniated disc
- tumor
Where do you assess potency of the nostrils?
CN1, olfactory
This is a palpable vibration while patient says “blue moon”
fremitus
Where do sounds for tactile fremitus originate?
- Generated from larynx > patent bronchi > lung parenchyma > chest wall (where you feel them)
Unequal chest expansion occurs with x4
- marked atelectasis;
- pneumonia;
- thoracic trauma;
- pneumothorax
This is coarse, crackling sensation palpable over the skin surface. Occurs in subcutaneous emphysema, when air escapes from the lungs and enters the subcutaneous tissue
Crepitus
This is soft, muffled thud; signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis or tumor
Dull
this is lower pitched, booming sound found when too much air is present, as in emphysema or pneumothorax
Hyperesonance
Occurs with compression or consolidation of lung tissue (e.g. lobar pneumonia) Present only when the bronchus is patent and when the consolidation extends to the lung surface.
Increased Fremitus
Occurs when anything obstructs transmission of vibrations. (e.g. obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema.
decreased fremitus
When could the apical impulse not be palpable
obese persons, or persons with thick chest walls.
When does the apical impulse increase in size and duration?
- anxiety,
- fever,
- hyperthyroidism
- anemia
This is a palpable vibration. It feels like a throat of a purring cat. Usually signifies turbulent blood flow with loud murmurs.
Thrill
this is felt over the precordium during systole in aortic stenosis, pulmonary stenosis, and ventricular septal defect.
systolic thrill
sometimes felt on percussing over a cyst.
hydatid thrill
this is felt over the precordium during ventricular diastole in advanced aortic insufficiency.
diastolic thrill
This is when ventricular filling creates vibrations
S3
Signs/Symptoms of DVT
- pain, swelling, tenderness in one of your legs (calf)
- warm skin where clot is located
- redness back of your leg below knee
- aching
Wha are reasons to administer an enema?
- Constipation
- Bowel preparation for procedures
While administering an enema you feel resistance, what is the appropriate nursing action?
Stop the procedure and notify the healthcare provider
What is the typical amount of time a client can hold the fluid in after an enema before expelling it?
2-5 minutes
When administering a regular enema, how high should you hold the enema bag?
12 inches
What is the correct thing to do if a clinet complains of cramping during the enema administration?
Lower the height of the enema bag
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
c) Instructing the patient to retain the enema for at least 30 sec
Your patient complains of an excessive flatulence. When reviewing your patients dietary intake, which foods, if eaten regularly, would you identify as possibly responsible?
A) Meet
B) Cauliflower
C) Potatoes
D) Ice cream
B) Cauliflower
Cauliflower is a gas producing food that relates in flatulence
Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this?
A) They will cause a fecal impaction
B) They will cause chronic constipation
C) They change the pH of the Gastrointestinal track
D) They inhibit the intestinal enzymes
B) Chronic constipation
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) Bradycardia
Removing a fecal impaction manually may result in stimulation of the vaginal nerve and resulting bradycardia
Which of the following is an appropriate nursing action to promote regular bowel habits?
A) Encourage the patient to avoid moving his bowels until a certain time of day
B) Encourage the patient to avoid excess fluid intake and too much fiber
C) Avoid strenuous exercise to limit stress on the abdominal muscles and impair peristalsis
D) Assisting the patient to a normal position as possible to defecate
D) Assisting the patient to a normal position as possible to defecate
Sitting upright on a toilet or commode promotes defecation. If the patient must use a bedpan, raise the head of the bed 30 to 45°. Patient should be encouraged to move their bowels at their usual time of the day.
What is the incidence of deep vein thrombosis?
Age-dependent
In a 50yo: 1/1,000 per year
Young adults: 1/10,000 per year
In elderly: 1/100 per year
What are the risk factors for DVT?
- obesity,
- cancers,
- major surgery,
- infection,
- chemotherapy,
- IV drug use,
- inacitivty and immobility,
- post-partum period,
- long-haul flights
What are the signs and symptoms of DVT?
- Distension of surface veins,
- pain/tenderness,
- redness/discolouration,
- swelling,
- warmth
What are subjective assessment questions for Cardiac x8
- 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
This is a condition in which one or more areas of your lungs collapse or don’t inflate properly.
Atelactic
What can cause infection in the Cardiac
- bad gums
- central line
- weak valve
- inflammation
Listening to the heart, what side of your stethoscope do you hear low pitched sounds?
The bell
What is a bruit?
turbulent blood flow
Pathological Reasons for Listening for S3
Anemia,
sign of HF
Volume overload
hyperthyroidism
pregnancy
renal failure
persists when sitting up
Reasons for listenting for S4
decreased compliance of ventricle
systolic overload
aortic stenosis
systemic hypertension
What are reasons for having a murmur
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
What is a resting adult CO
4-6 of blood/min
What is preload?
force of stretch in heart from venous return
What is afterload?
Ventricular pressure needed to eject blood
What happens heart/neck when Aging?
BP increases
lifestyles
sodium
Left ventricle increases
Increase Arrhythmias
Orthostatic Hypotension (getting out of bed fast)
check for bruits in carotid
systolic heart murmur
Where do you assess an adult heart
5th ICS
Where do you assess infant heart?
3-4 ICS
What is PMI referring to?
Point of Maximal Impulse
High risk factors for heart disease
high blood pressure
smoking
high cholesterol
diabetes
obesity
what type of assessment do you take for bruit?
Auscultate
What do blood vessels do?
transports blood which transports oxygen
What are you markers for major arteries?
ulnar, radial, brachial
Intraluminal valves help to ensure
blood moves towards the heart
What do varicose veins look like?
blue
torturous
you can fee
How would the skin present itself if you had arterial insufficiencies?
thin, shiny skin, thick nails
less hair on legs
used to evaluate the adequacy of collateral circulation prior to cannulating the radial artery;
Modified Allens Test
What and where are you looking for during a modified allens test?
- should see blanching
- compression on radial & ulnar arterties
Which lung lobe is shorter?
the right side, because of the liver
What is visceral pleura
sack for the lungs
What does negative pressure mean referring to the lungs
lungs are being pulled open, otherwise lungs would collapse
Where does gas exchange occur?
bronchial trees
What is controlling respiration
CO2
What is Hypercapnea
too much CO2
hypoxemia
low oxygen in the blood
What is the major muscle of inspiration
diaphram
Is expiration passive or active?
Passive
What causes crackles?
Too much fluid
What are discontinuous sounds?
- crackles
- atelectic crackles
- pleural friction rub
What are continuous sounds
wheeze, stridor
What type of breath sound is asthma
wheeze
What are 3 salivary glands
- parotid
- submandibula
- sublingua
What do stretch receptors initiate
contraction of sigmoid colon/rectal muscles
