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NUR 216: Health Assessment > Exam 3 Study Guide: Quizlet > Flashcards

Exam 3 Study Guide: Quizlet Flashcards

1
Q

the nurse is performing a respiratory assessment and detects a low pitch, sot sound. The inspiratory phase is longer than expiration. The nurse interprets this as?

A

vesicular sound

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2
Q

when percussing the chest, what sound would the nurse expect to hear over the lungs?

A

resonance

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3
Q

the nurse auscultates an extra sound over the left lower lobe. The nurse should: document finding,

A

Ask client to cough

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4
Q

upon auscultation the nurse detects an extra gurgling, expiratory sound in the upper airways. the nurse interprets this as?

A

rhonchi

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5
Q

inspection of the chest includes assessing the anterior-posterior: lateral ratio. the normal finding for an adult is:

A

1:2

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6
Q

the nurse is performing a cardiac assessment. Which site is best for palpating the PMI?

A

apex

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7
Q

the nurse detects a trill while palpating the carotids. what sound would the nurse expect to hear when auscultating the carotids?

A

bruit

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8
Q

how would the nurse differentiate carotid from venous pulsations?

A

jugulars affected by breathing

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9
Q

during cardiac auscultation, the nurse detects a low pitch early diastolic sound at the apex. the nurse interprets this as:

A

S3

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10
Q

there are many different causes of chest pain. Which area should be addressed first when a client presents with chest pain?

A

cardiac

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11
Q

where are bronchovesicular sounds heard?

A

over major bronchi near sternal notch

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12
Q

where are bronchial sounds heard?

A

over trachea or larynx, up by clavicle

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13
Q

where are vesicular sounds heard?

A

over peripheral lung fields - mostly what we listen to

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14
Q

Causes, sounds, and associated conditions of Rales/Crackles?

A

caused by air passing through fluid

sounds like bubbling/crackling like rice crispy
soft, high-pitched, very brief
usually on inspiration

pulmonary edema
atelectasis
fibrosis
pneumonia

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15
Q

causes, sounds, and associated conditions of wheezes?

A

narrowing of airway passages

can be heard on inspiration or expiration

asthma
COPD

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16
Q

cause, sounds, and associated conditions of rhonchi?

A

mucous secretions in large airway

coarse, snoring, low-pitched, continuous sounds
usually on expiration but can be on inspiration as well

might snore from mucous build up
may clear with coughing

pneumonia
bronchitis
emphysema

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17
Q

cause, sounds, and associated conditions of friction rub?

A

inflammation in pleural spaces

high-pitched grating or rubbing sound

best heard over lower lateral lungs

infection/inflammation of pleura - pleuritis

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18
Q

cause, sounds, and associated conditions of stridor?

A

medical emergency - partial airway obstruction
child swallowed object, laryngeal spasms, or epiglottitis

high-pitched continuous honking sound

prominent on inspiration

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19
Q

cause, sounds, and associated conditions of grunting

A

retention of air in the lungs

high-pitched tubular sound
heard on expiration

emphysema - unable to fully exhale

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20
Q

what is the pathway of the electrical impulse through the heart?

A

starts in the right atria at the SA node

across the internodal pathways to left atria

AV node then bundle of his where there is a short pause

down right and left bundle branches to purkinje fibers which contract the ventricles

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21
Q

what is the pathway of blood through the heart?

A

superior and inferior vena cava
right atrium
tricuspid valve
right ventricle
pulmonary valve
pulmonary artery
lungs
pulmonary vein
left atrium
mitral valve
left ventricle
aorta
body

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22
Q

what are symptoms of left-sided heart failure?

A

blood backs up into the lungs

pulmonary congestion
cough
blood-tinged sputum
tacypnea
tachycardia
restless
confusion
dyspnea - worse with exertion
cyanosis - check MM/sclera in patient with darker skin tone
fatigue
lung sounds: crackles and wheezes

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23
Q

what are the symptoms of right-sided heart failure?

A

blood backs up coronary vein

fatigue
increased JVD
ascites
hepatosplenomegaly
anorexia
weight gain
edema

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24
Q

what are modifiable risk factors for hypertension?

A

alcohol intake
smoking
stress
obesity
stress
diet
lack of exercise

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25
Q

what are non-modifiable risk factors for hypertension?

A

family hx
age 65 and older

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26
Q

what are symptoms of peripheral artery disease?

A

hair loss on lower limbs
weak or absent peripheral pulses
ulcerations in toes and lower limbs that do not bleed
pain with walking
legs cool to the touch

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27
Q

what are symptoms of peripheral venous disease?

A

develop wounds that usually have drainage

skin gets very thick and brown

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28
Q

how many lobes are in each lung?

A

right = 3
left = 2

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29
Q

what is the order of techniques for the respiratory assessment?

A

inspection, palpation, percussion, auscultation

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30
Q

lining of the lungs

A

pleura

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31
Q

major airway passages of the lungs

A

bronchi

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32
Q

smaller airway passages of the lungs

A

bronchioles

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33
Q

location of gas exchange

A

alveoli

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34
Q

where can you check for cyanosis?

A

conjuctiva
oral mucous membranes
anywhere without heavy pigmentation

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35
Q

what lung changes occur in an older adult?

A

loss of tissue elasticity
increased rigidity
difficult to inflate
increased risk for pneumonia

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36
Q

what is the benefit of increased hydration to a pneumonia patient?

A

thin secretions

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37
Q

who is at increased risk for pneumonia?

A

COPD patients
older adults

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38
Q

what are typical subjective and inspection findings for COPD patient?

A

subjective:
dyspnea
chronic productive cough
fatigue

inspection:
tachypnea
productive cough
clubbing
increased AP diameter
accessory muscle use
short shallow breaths
prolonged expiration
O2 sat levels low 88-89% or even lower

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39
Q

what are typical percussion and auscultation findings for a COPD patient?

A

percussion:
decreased diaphragmatic excursion
hyperresonance due to trapped air

auscultation:
decreased breath sounds
possible occasional wheeze and crackles

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40
Q

what is a side effect of opioids?

A

CNS depression - bradypnea
shallow respirations

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41
Q

what is normal RR?

A

12 - 20 bpm

42
Q

what is bradypnea RR?

A

< 12 bpm

43
Q

what is tachypnea RR?

A

> 20 bpm

44
Q

what are ways to prevent respiratory complications post op?

A

encourage inspiratory spirometer (IS) every hour while awake

brush teeth BID

encourage the client to cough and deep breath

sit in chair for each meal

45
Q

what is the order of techniques for cardiovascular assessment?

A

inspection, palpation, auscultation

(no percussion)

46
Q

what do you need to do if the radial pulse is irregular?

A

auscultate the apical pulse for a full minute

47
Q

what is a pulse deficit?

A

difference between the radial and apical pulse

48
Q

what do each of the pulse scores mean?

A

0 = absent pulse
1+ = weak, diminished, thready
2+ = normal, brisk
3+ = full
4+ = bounding

49
Q

in the absence of disease, how do you characterize peripheral pulses?

A

symmetrical strength
quality
quantity

50
Q

how does systolic BP, CO, and arterial walls change with age?

A

systolic BP: increases
CO: decreases
arterial walls: thicken

51
Q

what is the meaning of systolic blood pressures?

A

how much pressure is exerted against artery walls during ventricular contraction

52
Q

what is the meaning of diastolic blood pressures?

A

how much pressure is exerted against artery walls while the heart is resting between beats

53
Q

what is the criteria and symptoms orthostatic hypotension?

A

drop in blood pressure >20 systolic with position changes

dizziness, weakness, and fainting

54
Q

what position and tools are required to assess for JVD?

A

elevate patients head to 45 degrees or semi-fowlers

use a penlight

55
Q

what is occurring during S1 heart sounds?

A

S1 = lub
AV valve (mitral and tricuspid) closure

56
Q

what is occurring during S2 heart sounds?

A

S2 = dub
aortic and pulmonic valve closure and marks the beginning of diastole

57
Q

what causes a swishing sound during cardiovascular auscultation?

A

murmurs -
could indicate the presence of heart disease and valve malfunction

58
Q

what 4 peripheral pulses can be palpated in the lower extremities?

A

femoral pulse
popliteal pulse
posterior tibial
dorsalis pedis

59
Q

what symptoms would have higher priority than chest pain?

A

airway and breathing - ex dyspnea

chest pain abnormal cardiovascular finding and related to curculation

60
Q

what is a barreled chest and what disease is associated with this finding?

A

altered shape
1:1 length to width ratio

COPD
chronically overinflated lungs so rib cage remains partially expanded

61
Q

what are normal percussion findings during respiratory assessment?

A

anterior chest:
resonance to 2nd ICS on left to 4th ICS on right

62
Q

what are abnormal percussion findings during respiratory assessment?

A

dullness:
tumors
fluid
pleural effusion
pneumonia
pulmonary edema

63
Q

what changes occur with an older client’s blood pressure?

A

increased systolic

64
Q

which patient should you see first:
one with hypertension
one who is leaving for surgery
or one who has chest pain?

A

chest pain

65
Q

which can AP perform for you:
palpate pedal pulses
performed health history
put a patient on oxygen
or document intake/output?

A

document intake/output

66
Q

when auscultating the heart and listening for high pitched sounds, what part of the stethoscope do you use?

A

diaphragm

67
Q

if you gave a client medications then come back in 30 min to see how they are,
what part of nursing process is this?

A

evaluation

68
Q

when BP drops with positional changes,
what is that called and what nursing diagnosis can be used?

A

orthostatic hypotension

risk for falls
risk for injury

69
Q

what is occurring during lub heart sound?

A

AV valve closure

70
Q

what occurs during dub heart sound?

A

aortic and pulmonic valves closing

71
Q

bubbling popping rattling lung sounds are called?

A

crackles

72
Q

high pitched musical squeaking lung sound are called?

A

wheezes

73
Q

how do you evaluate a patient to see if breathing medication worked?

A

listen to lungs to see if wheezing improved

74
Q

which patient do you see first:

one waiting for discharge
someone screaming for morphine
or a patient with dyspnea?

A

patient with dyspnea

75
Q

why are older adults at a higher risk for pneumonia?

A

lungs are rigid and harder to inflate

76
Q

what step is first in respiratory assessment?

A

inspection:

look for scars
assess respiratory rate
rhythm
depth
symmetry of chest movement
barrel chest
spinal deformities
accessory muscle use
intact skin

77
Q

when auscultating the lungs, how long should you listen in each spot?

A

one full ventilation - inhale / exhale

78
Q

what is the correct direction of lung sound auscultation?

A

side to side to compare

79
Q

how do you determine if there is a pulse deficit?

A

one nurse counts the radial pulse while one nurse counts the apical pulse for one minute then subtract the difference

80
Q

who is at the greatest risk for developing pneumonia after having a procedure:

a 32yo who just had abdominal surgery
an 82yo with syncope
an 18yo refusing to ambulate
or a 45yr with COPD

A

45yo with COPD -
encourage patient to get pneumovax as it is very difficult to recover from pneumonia with COPD

81
Q

which pulse is never assessed bilaterally at the same time?

A

carotid
will cut off brain blood flow

82
Q

post-bp patient needs to do what to prevent pneumonia?

A

sit up in chair for each mail
oral care BID
incentive spirometer - 5-10 hourly while awake
cough and deep breathe

83
Q

which patients are the most susceptible to environmental pollution?

A

patients with asthma

84
Q

how can patients prevent COPD and what is the number 1 cause of this disease?

A

stop smoking

85
Q

what is the cause of high pitched monophonic crowing sound and patient has croup, how high of priority is this patient?

A

stridor

number 1 - caused by an obstruction

86
Q

where is erb’s point?

A

3rd ICS, left of the sternum

87
Q

when you hear S1/S2 but the heart rate is 120 bpm, what is this called?

A

sinus tachycardia

88
Q

what is the term for short high pitched popping sounds over the lung bases that usually disappear after a few deep breaths and coughs?

A

fine crackles - alveoli deflated right after waking up

89
Q

primary pacemaker of the heart is?

A

SA Node

90
Q

what is the term for the low-pitched snoring sound heard over the bases?

A

Rhonchi

91
Q

if you can’t palpate a pulse, what should you use?

A

doppler

92
Q

where does gas exchange occur?

A

alveoli

93
Q

what is eupnea?

A

normal breathing

94
Q

if patient had RR of 30, are they in respiratory distress?

A

yes

95
Q

how do you calculate cardiac output?

A

co = sv x hr

96
Q

what causes a soft low pitched rushing sound?

A

bruit

97
Q

what are 4 findings with a COPD patient?

A

barreled chest
chronic productive cough
tachypnea
clubbing
fatigue
accessory muscle use
prolonged expiration
SpO2 88-92% or lower

98
Q

when taking a manual BP, what artery are you listening to?

A

brachial

99
Q

where do you assess for a popliteal pulse?

A

behind the knee

100
Q

what is a normal CRT?

A

< 2 seconds

101
Q

what is the correct order of techniques for a cardiac assessment?

A

inspection
palpation
auscultation

(dont have to percuss heart)

NUR 216: Health Assessment (7 decks)

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