Jen ch 30 Part II

Question 0

Crackles

Answer 0

Caused by random, sudden reinflation of groups of alveoli or disruptive passage of air through small airways. Canned be described as fine, medium, or course

Question 1

When assessing thorax and lungs:

Answer 1

Inspect for deformities, position of the spine, slope of the ribs, retraction of intercostal spaces during inspiration, bulging of intercostal spaces, and rate and rhythm of breathing

Question 2

Rhonchi

Answer 2

Low pitched, continuos sounds caused by muscular spasm, fluid, or mucus in larger airways; or new growth or external pressure causing turbulence

Question 3

Wheezes

Answer 3

High pitched continuous squeak during inspiration or expiration. Louder on expiration; often heard in asthma

Question 4

Pleural friction

Answer 4

Dry rubbing or grating sound caused by inflamed pleura: parietal pleura rubbing against visceral pleura

Question 5

PMI

Answer 5

Point of maximal impulse for palpating of heart similar placement to apical pulse

Question 6

S1, S2, S3, S4

Answer 6

S1 and S2 “lub/dub” S1 hearts chambers fill with blood, S2 chambers empty of blood, S3 can be heard when heart attempts to fill already distended ventricle, S4 occurs when atria contract to enhance ventricular filling (S4 not normally heard in adults)

Question 7

Six anatomical landmarks of heart:

Answer 7

Aortic, pulmonic, second pulmonic, tricuspid, mitral, epigasric (Ape 2 man?)

Question 8

Atrial gallop

Answer 8

S4

Question 9

Assessing vascular system:

Answer 9

Carotid arteries, jugular veins, peripheral arteries, peripheral veins, tissue perfusion, lymphatic system

Question 10

BP Readings between arms

Answer 10

Right arm tends to be higher - always record highest measurement

Question 11

Do not _____ the carotid artery and why

Answer 11

Do not palpate or massage the carotid artery vigorously because carotid sinus located at bifurcation of common carotid arteries in upper third of neck and sinus sends impulse to vagus nerve - stimulation causes reflex drop in heart rate and BP (can cause syncope or circulatory arrest.)

Question 12

Occlusion

Answer 12

Blockage

Question 13

Jugular vein

Answer 13

Most accessible, right internal JV best to examine because has more direct path to right atrium of heart, when lying down ext. JV will distend and easily visible, if distended when sitting can be a sign of heart disease

Question 14

Lack of pulse

Answer 14

Can indicate arterial issues

Question 15

Ulnar pulse used when

Answer 15

Evaluating arterial insufficiency to the hand

Question 16

Phlebitis

Answer 16

Irritation of vessels

Question 17

Variscosities

Answer 17

Superficial veins that become dilated, esp. when legs in dependent position

Question 18

Abdomen inspection

Answer 18

Inspect, palpate, auscultate, check liver, stomach, uterus, ovaries, kidneys, bladder, umbilicus, contour and symmetry, enlarged organs or masses, movements or pulsations

Question 19

Abdomen auscultation

Answer 19

Bowel motility (peristalsis, borborygmi), vascular sounds (bruits)

Question 20

Abdomen palpation

Answer 20

Detect tenderness, distention, masses, aortic pulsation

Question 21

musculoskeletal system general inspection

Answer 21

Gait, postural abnormalities, age related changes

Question 22

Crepitus

Answer 22

Joint sounds - rice krispys

Question 23

ROM, AROM, PROM

Answer 23

Range of motion, active and passive

Question 24

Neurological assessment

Answer 24

Variables considered: LOC (level of consciousness), physical status, chief complaint, mental and emotional status, cultural considerations

Question 25

MMSE

Answer 25

Mini-Mental State Examination- measures orientation and cognitive function

Question 26

Delirium

Answer 26

Acute mental disorder, characterized by confusion, disorientation, and restlessness

Question 27

Glasgow Coma Scale

Answer 27

Objective measurement of consciousness on a numerical scale for patients with lower consciousness

Question 28

Intellectual function assessment

Answer 28

Memory (recent, immediate, past), knowledge, abstract thinking, association, judgment

Question 29

Motor function assessment

Answer 29

Tests: coordination, higher and lower extremity/fine-motor control, balance, gross motor function

Question 30

Clonus

Answer 30

muscular spasm involving repeated, often rhythmic, contractions.

Question 31

After the exam:

Answer 31

• Record findings
• Give patient to dress (assist if needed)
• talk to doc before patient if serious issues
• ensure exam room cleaned
• review assessment for accuracy
• communicate significant findings w/ patient