FINAL Flashcards
what are the different types of lung sounds (3)
- broncial
- bronchialvesicular
- vesicular
characteristics of bronchial breath sounds
harsh, high pitched, loud
what is an abnormal breath sound
adventitious
characteristics of bronchialvesicular sounds
blowing, moderate intensity, moderate pitch
which patient has a barrel chest
emphysema
what is a more horizontal position of the ribs, costal angle of more than 90*
barrel chest
positive sign of the romberg test
moving feet apart
characteristics of the soft palate
pink, smooth, moist
CN that assesses the gag reflex
CN IX and X
4 things to look for when assessing mental status
- memory
- speech
- reasoning
- judgement
where to percuss the triceps reflex
above the olecranon process
suggestive of breast malignancy
retraction of the breast
CN that is tested by clenching teeth
trigeminal nerve
type of assessment that is performed for a particular problem
focused
when should a clinical breast exam be done
every 3 years for young adult women
dysfunction of CN VIII
vertigo
when objects look blurry up close
presbyopia
sound that is heard when auscultating the heart in CHF pt’s
S3
slow, less than normal
brady
characteristics of vesciular breath sounds
sighing, low pitch, soft intensity
4 adventitious lung sounds
- crackles (rales)
- ronchi (gurgles)
- friction rub
- wheeze
organ that is in the ULQ
spleen
where the mitral/apical pulse is located
5th ICS, MCL
tests for low back pain
straight leg test
what does documentation promote
communication between team members
when to use a Doppler
if there is a non-palpable pulse where there was not an absent pulse before change
where the apex/apices of the lungs located
slightly above the clavicles
orthopnea
difficulty breathing when lying supine
*indicative of CHF
tripod position is assoc. with
seen in pt’s with COPD
CN for smell
CN I (olfactory)
clear watery drainage from the ear
CSF
race and gender that has a higher risk for heart failure
African American male
when do you palpate the abdomen
last
infection of the ear that causes a tender tragus
otitis externa
pulse that is used to assess for arrhythmias
apical
foundation of the nursing process
assessment
when kyphosis is normal
in older adult pt’s
- hunchback
- overexaggerated curve in the posterior aspect of the spine
dimpling or retraction of the breast is usually caused by f
malignant tumor
pig-skin like or orange-peel appearance results from edema is seen in
metastatic breast disease
Peau d’orange results from
edema
metastatic breast disease
tingling, itching, increased sensitivity, burning, discharge, and pain in the nipple are late signs of
Paget’s disease
where to assess pallor in a dark skinned client
buccal mucosa
vagus nerve dysfunction
drooling
when an older pt c/o weakness and fatigue, 1st thing RN should do
RULE OUT ANEMIA
infection that can cause absent bowel sounds
peritonitis
ask client to __ when auscultating their thyriod
hold breath
used to measure angles
goniometer
used to maintain privacy and confidentiality of pt’s
HIPPA
characteristics of resonance
when percussing loud low pitched hollow sounds
5 sounds elicited from percussion of lungs and location
- flatness (muscle/bone)
- dullness (dense tissues)
- resonance (lungs filled with air)
- hyperresonance (assoc. c. emphysema pt’s)
- tympany (air-filled stomach)
priority of carotid assessment
auscultation
characteristics of cluster headache
pain to the eye and temple
how to percuss the sinuses
percuss
characteristics of arterial insufficiency
deep, cervical, painful ulver
consensual response (2)
indirect response
other pupil constricts when light is shone into eye
part of the brain that controls balance and coordination
cerebellum
describe petechiae
small, flat, reddish, purple macules
if a pt has a score of 7 on the GCS, this pt is __
in a coma
if a pt has a score of 14 on the GCS, this pt is __
WNL
method of interview process that is exploring and investigating symptoms
Dr. gives an order over the phone. what should you do before you disconnect the call?
read back the order
internally rotating the lower extremities
decorticate
__ can cause pinpoint pupils
narcotics
visual disturbance in the prodromal stage
migraine
most common pulse site
radial
where is referred rebound tenderness located
LLQ
what test requires the use of a tuning fork to the mastoid process
Rinne
test to assess knee swelling
bulge test
if a pt has a hip fx, what will they complain of
thigh pain
normal degree of lumbar and thoracic extension
30*
describe macule
flat, non-palpable lesions
organ that causes RUQ and shoulder pain
gallbladder
what do you assess for when using bronchophony
use phrase “ninety-nine”
what do you assess for when using whispered pectiloroquy
use phrase “1-2-3”
sibilant wheezes are heard in what types of pt’s
acute asthma
chronic emphysema
fine crackles are heard in what types of pt’s
PNA
CHF
coarse crackles are heard in what types of pt’s
PNA
PE
pulmonary fibrosis
sonorous wheezes are heard in what types of pt’s
bronchitis
single obstructions
snoring before an episode of sleep apnea
what race has a larger thorax and greater lung capacity
Caucasians
decreased respiratory rate, decreased depth, irregular pattern
hypoventilation
regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea
Cheyene-Stokes respiration
irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea
Biot’s respirations
rapid, deep, labored breathing
Kussmaul
pectus carinatum AKA…
pigeon chest
