Exam 4 Kaplan Review Flashcards
Breathing accomplished by abdominal muscles and diaphragm; may be used
to increase effectiveness of ventilatory process in certain conditions. What type of breathing pattern is this?
Abdominal respirations
Produces respiratory alkalosis due to reduction in CO2 tension. What type of breathing pattern is produced by this?
Hyperventilation
Difficult, labored, or painful breathing (considered “normal” at certain times, e.g., after extreme physical exertion). What type of breathing pattern is this?
Dyspnea
This contains the voice box and epiglottis, which prevents food from entering the trachea;
cough reflex. This is what structure of the upper respiratory system?
Larynx
Periodic breathing characterized by rhythmic waxing and waning of the depth of respirations. What type of breathing pattern is this?
Cheyne-Stokes respirations
Abnormally rapid, deep, and prolonged breathing. What type of breathing pattern is this?
Hyperventilation
Abnormal breath sounds. What type of breathing pattern is this?
Adventitious lung sounds
Rate, depth, or tidal volume changes markedly from one interval to the next; pattern of change is periodically reproduced. What type of breathing pattern is this?
Periodic breathing
Breathing pattern in which a lung (or portion of a lung) deflates during inspiration (acts opposite to normal). What type of breathing pattern is this?
Paradoxical respirations
Inability to breathe except when trunk is in upright position. What type of breathing pattern is this?
Orthopnea
Marked increase in depth and rate of breathing. What type of breathing pattern is this?
Kussmaul’s respirations (air hunger)
Reduced ventilatory efficiency; produces respiratory acidosis due to elevation in CO2 tension. What type of breathing pattern is this?
Hypoventilation
Gurgling, bubbling, or popping sounds; heard mostly on inspiration and not cleared by coughing. May be high-pitched (fine crackles), medium-pitched (medium crackles), or low-pitched (coarse crackles). May clear with coughing. What adventitious lung sound matches this description?
Crackles (Rales)
High-pitched, musical sounds similar to a squeak. Heard more commonly on expiration, but may be heard on inspiration. Auscultated over small airways. Do not clear with coughing. What adventitious lung sound matches this description?
Wheeze
Harsh, high-pitched sounds heard over
the trachea. What adventitious lung sound matches this description?
Stridor
A superficial, low-pitched, coarse rubbing or grating sound (sounds like two surfaces rubbing together). Heard throughout inspiration and expiration and not cleared by coughing. What adventitious lung sound matches this description?
Pleural Friction Rub
Needed for blood clotting, skeletal muscle contraction, regulated by the parathyroid hormone and vitamin D, which facilitates reabsorption of calcium from bone and
enhances reabsorption from the GI tract. What electrolyte is required during these processes?
Calcium
- Increased intake of dietary Mg—green vegetables, nuts, bananas, oranges, peanut butter, chocolate
- Oral—long-term maintenance with oral magnesium
- IV—assess renal function
- Monitor for digitalis toxicity
- Seizure precautions
6 Safety measures for confusion - Test ability to swallow before PO fluids/food because of dysphagia
These are nursing interventions for what electrolyte imbalance?
Hypomagnesemia
- Malignant neoplastic diseases
- Hyperparathyroidism
- Prolonged immobilization
- Excessive intake
- Immobility
- Excessive intake of calcium carbonate antacids
These ailments can cause what electrolyte imbalance?
Hypercalcemia
Acute Pain: Fluid intake reduced
Activation of sympathetic nervous system
Chronic Pain: Stress-induced changes
Pain has this effect on what body system?
Cardiovascular System
normal ionized serum calcium level:
____-____ mg/dL;
normal total serum calcium level:
____-____ mg/dL
- 5–5.2 mg/dL
8. 5–10.5 mg/dL
- Lack of coordination
- Anorexia, nausea, and vomiting
- Confusion, decreased level of consciousness
- Personality changes
- Dysrhythmias, heart block, cardiac arrest
These are signs and symptoms of what electrolyte imbalance?
Hypercalcemia
Acute Pain: Nausea and vomiting
Chronic Pain: Constipation, anorexia
Pain has this effect on what body system?
Digestive system
Tap facial nerve 2 cm anterior to the earlobe just below the zygomatic arch;
twitching of facial muscles indicates tetany in hypocalcemia. What is this sign to indicate tetany called?
Chvostek’s Sign
This is the main intracellular ion; involved in cardiac rhythm, nerve transmission. What electrolyte is required during these processes?
Potassium
Potassium Normal level ___-___ mEq/L
3.5–5.0 mEq/L
Inflate BP cuff on upper arm to 20 mm Hg above systolic pressure, carpal
spasms within 2–5 min indicate tetany in hypocalcemia. What is this sign to indicate tetany called?
Trousseau’s Sign
- EKG changes–peaked T waves, wide QRS complexes
- Dysrhythmias, ventricular fibrillation, heart block
- Cardiac arrest
- Muscle twitching and weakness
- Numbness in hands and feet and around mouth
- Nausea
- Diarrhea
These are signs and symptoms of what electrolyte imbalance?
Hyperkalemia
- Restrict dietary potassium and potassium-containing medications or IV solutions
- Sodium polystyrene sulfonate (Kayexalate)—cation-exchange resin (causes diarrhea)
a. Orally—dilute to make more palatable
b. Rectally—give in conjunction with sorbitol to avoid fecal impaction - Peritoneal or hemodialysis
- Diuretics
These are nursing interventions for what electrolyte imbalance?
Hyperkalemia
- Vomiting
- Gastric suction
- Prolonged diarrhea
- Diuretics and steroids
- Inadequate intake
These ailments can cause what electrolyte imbalance?
Hypokalemia
- Anorexia, nausea, vomiting
- Weak peripheral pulses
- Muscle weakness, paresthesias; decreased deep tendon reflexes
- Impaired urine concentration
- Ventricular dysrhythmias
- Potential for digitalis toxicity
- Shallow respirations
These are signs and symptoms of what electrolyte imbalance?
Hypocalcemia
- Administration of oral potassium supplements—dilute in juice and give with meals to avoid gastric
irritation - Increase dietary intake—raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery
- Assess renal function prior to administration of IV supplements
- Risk for digitalis toxicity
These are nursing interventions for what electrolyte imbalance?
Hypokalemia
This is the main extracellular ion; responsible for water balance. What electrolyte is required during these processes?
Sodium