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Health Assessment I > Lung Assessment > Flashcards

Lung Assessment Flashcards

1
Q

Name the anterior reference lines

A

Midclavicular and medial line

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2
Q

Pt is dehydrated. What sound might you hear when auscultating lungs?

A

Pleural rub (when you step on snow)

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3
Q

Pt has pneumonia. Pt complains of pain when breathing.

A

Pleuritis

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4
Q

When I lay down, I feel like I cannot breathe. I can place pillows behind me and that helps.

A

Orthopnea

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5
Q

What is orthopnea?

A

Difficulty breathing when laying down

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6
Q

What is parozysmal nocturnal dyspnea?

A

In the middle of night, the pt has trouble sleeping. And they wake up in the middle of the night. Feeling like they were not breathing.

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7
Q

I am having trouble breathing. This is known as…

A

Dyspnea

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8
Q

I snore and sometimes I feel like I have to gasp for a breath

A

Sleep apnea

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9
Q

You have a pt who has no history of respiratory issues and is basically healthy. The nurses is auscultating and hearing adventitious lung sounds. What do you ask the pt to do?

A

Ask patient to cough

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10
Q

Order of the lung assessment?

A

Inspection, Palpation, Percussion, Auscultation

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11
Q

Patient has a barrel chest, what assessment phase is this?

A

Inspection

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12
Q

Patient is cyanotic, what assessment phase is this?

A

Inspection

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13
Q

The patient’s chest rises and falls evenly, what assessment phase is this?

A

Inspection

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14
Q

You are observing your pt during respirations and you notice their chest appears to sink in just below the neck, under the breastbone, rib cage, and intercostal spaces. Why is this happening?

A

The patient is compensating by attempting to bring in more air into the lungs

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15
Q

Kyphosis

A

Hunchback. May be related to osteoporosis in the elderly.

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16
Q

When we palpate, what are we looking for?

A

To check for crepitus pain, tenderness, edema, proper motions

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17
Q

When palpating, you feel a crackling sensation. What could this be?

A

Crepitus

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18
Q

What is tactile fremitus?

A

Vibrations

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19
Q

You assess for tactile fremitus. You place your hands on their back ad ask them to say “99.” Why do you do this?

A

You want it to feel the same on both sides

20
Q

What does it mean if there is unequal vibrations when palpating for tactile fremitus?

A

Consolidation on one side of the lung.

21
Q

What sounds could we hear when we percuss?

A

Tone (hollow sounds on both sides),
Hyperresonance (air trapped in the lungs),
Dullness (i.e., over a solid or liquid tumor)
Resonance (low pitch sound over healthy tissue)
Diaphragmatic excursion (measuring the movement of the diaphragm)

22
Q

What is emphysema?

A

Loss of elasticity in alveioli, therefore, air gets trapped

23
Q

What sound do you hear when the pt has emphysema

A

Resonance

24
Q

Usually we are listening to…

A

vesicular sounds

25
Q

Bronchial sounds are heard during

A

expiration

26
Q

Vesicular sounds are heard during

A

inspiration

27
Q

Bronchovesicular sounds are heard during

A

both

28
Q

You ask your pt to repeat “99” while you auscultate their chest. What is this called?

A

Bronchophony

29
Q

During auscultation, you notice it is easy to under the “99” sound. Should you concerned?

A

Yes. May indicate a tumor or pneumonia

30
Q

You ask your pt to repeat “E” while you auscultate their chest. What is this called?

A

Egophany

31
Q

You ask your pt to repeat “E” while you auscultate their chest. The E sounds like A. Is this concerning?

A

Yes. Possible fluid in the lungs.

32
Q

You ask your pt to whisper “123” while you auscultate their chest. What is this called?

A

Whisper pectoriloquy

33
Q

During your respiratory assessment, you auscultate a high pitched sound during inspiration. What do you document this as?

A

Stridor

34
Q

Pt is admitted to Ed with exacerbation of asthma. What is the most prominent adventitious sound you are likely to hear and what causes it?

A

Wheezing.
Inflammation and bronchospasm.

35
Q

Pt has been admitted into the ICU with a TBI (traumatic brain injury). Their respirations are sometimes deep, sometimes shallow, and occasional apnea. How will you document this?

A

Biot

36
Q

Pt who is in hospice is now deep and rapid breathing, followed by periods of apnea. How will you document this?

A

Cheyne Stokes

37
Q

A pt is brought into the ED in diabetic ketoacidosis (DKA) They appear to be hyperventilating. How will you document this?

A

Kussmauls

38
Q

Common variations in older adults

A

Increased chest diameter
Kyphosis
Decreased thoracic expansion
Use of accessory muscles to exhale
At risk for fractures (osteoporosis)
Experiencing dyspnea with aging lungs
Decreased ability to cough

39
Q

Difference between kyphosis and scoliosis?

A

Kyphosis is the rounding of the thoracic spine
Scoliosis is a lateral deviation of the spine

40
Q

If someone has long term clubbing, can it be indicative of pulmonary difficulties?

A

Yes, chronic

41
Q

What are symptoms of pulmonary edema?

A

dyspnea, restlessness, cyanosis, pink frothy sputum

42
Q

It is difficult to palpate as it lies behind the clavicle

A

First rib

43
Q

A loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields.

A

Resonance

44
Q

Very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema.

A

Hyper-resonance

45
Q

Loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach

A

Tympany

46
Q

Medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.

A

Dullness

47
Q

During palpation of a client’s organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing what kind of palpation

A

Deep palpation

Health Assessment I (6 decks)

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