Week 3 Flashcards
Where is the apical impulse located?
A. In the fifth intercostal space at the midclavicular line
B. In the third intercostal space at the left sternal border
C. In the second intercostal space at the left sternal border
D. In the second intercostal space at the right sternal border
A. In the fifth intercostal space at the midclavicular line
Auscultatory sites of the heart include:
A. Systolic and diastolic murmurs
B. Bruits and thrills
C. Aortic, pulmonic, tricuspid, and mitral areas
D. Extra heart sounds and splitting
C. Aortic, pulmonic, tricuspid, and mitral areas
Which of the following findings during a cardiac assessment of an adult patient are considered normal?
A. Ejection or systolic clicks
B. Pericardial friction rubs
C. Murmurs
D. S1 and S2 sounds
D. S1 and S2 sounds
The S1 heart sound:
A. Is louder at the apex of the heart
B. Results from closure of the mitral and tricuspid valves
C. Marks the start of systole
D. All of the above
D. All of the above
When palpating the carotid arteries:
A. Palpate one artery at a time.
B. Feel for thrills.
C. Use the thumb to palpate.
D. Both A and B
D. Both A and B
What is the correct order for abdominal assessment?
A. Inspection, palpation, auscultation, percussion
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, palpation, percussion
D. Palpation, inspection, auscultation, percussion
B. Inspection, auscultation, percussion, palpation
How often should normal bowel sounds be heard in each quadrant of the abdomen?
A. 5–35 times per minute
B. Less than 5 times per minute
C. 15–20 times per minute
D. 20–40 times per minute
A. 5–35 times per minute
Which of the following is an important part of performing an abdominal assessment?
A. Completing the assessment as quickly as possible
B. Stopping the assessment if the patient has any tenderness
C. Explaining each step of the assessment to the patient
D. Having the patient talk when auscultating for bowel sounds
C. Explaining each step of the assessment to the patient
What should you do if a patient is ticklish when you are palpating the abdomen?
A. Distract the patient by talking to him or her.
B. Do not palpate the abdomen in the upper quadrants.
C. Do only deep palpation of all four quadrants.
D. Place your hand over the patient’s hand during palpation.
D. Place your hand over the patient’s hand during palpation.
Moderate and deep palpation of the abdomen:
A. May cause tenderness
B. Should not detect masses
C. Should never be done over a surgical incision
D. All of the above
D. All of the above
What is included in the preparation for an assessment of the female genitalia?
A. Having the patient empty the bladder
B. Explaining the exam thoroughly if it is the patient’s first exam
C. Laying the head of the table flat
D. Both A and B
D. Both A and B
When should gloves be changed or discarded?
A. After touching the genital skin
B. After completing the internal vaginal exam
C. After completing the rectal exam
D. All of the above
D. All of the above
Which description is consistent with normal vaginal secretions?
A. Clear, thick, and with a fishy odor
B. Clear or cloudy, and odorless or with a slight odor
C. Yellow, thin, and with a strong odor
D. Green, thick, and with a foul odor
B. Clear or cloudy, and odorless or with a slight odor
What is a Pap smear?
A. A screening test for cervical cancer
B. A screening test for colon cancer
C. A screening test for sexually transmitted diseases
D. None of the above
A. A screening test for cervical cancer
Screening for endometrial cancer consists of reinforcing the need to report:
A. Bloody stools
B. Painful bowel movements
C. Unexpected vaginal bleeding or spotting
D. Green or yellow vaginal discharge
C. Unexpected vaginal bleeding or spotting
Symptoms of prostate enlargement (NUTS)
Nocturia
Urine dribbles
Tries to void but can’t
Small urine stream
Which of the following should be included in a male genital exam?
A. Teaching the patient how to do self-exams
B. Palpating for abnormalities
C. Retracting and replacing the foreskin in an uncircumcised patient
D. All of the above
D. All of the above
Nocturia, urine dribbles, difficulty voiding, and a small urine stream are common symptoms of which of the following conditions?
A. Colorectal cancer
B. Benign prostatic hypertrophy
C. Testicular cancer
D. Hernias
B. Benign prostatic hypertrophy
In which patient population does benign prostatic hypertrophy occur most commonly?
A. Males over 50 years of age
B. Adolescent males
C. Males between 20 and 35 years of age
D. Males between 35 and 50 years of age
A. Males over 50 years of age
Which of the following patients are considered at increased risk for colon cancer?
A. Patients with a history of chronic inflammatory bowel disease
B. Patients with a family history of adenomatous polyposis
C. Patients with a history of appendicitis
D. Both A and B
D. Both A and B
Which possible signs and symptoms of testicular cancer should be reported to a physician?
A. A lump, tenderness, or swelling in the scrotum or testicles
B. Unexplained weight loss
C. Breast development
D. All of the above
D. All of the above
Which of the following techniques is used to assess muscle strength in a patient?
A. Apply an opposing force or resistance.
B. Observe the patient at rest.
C. Percuss the muscle.
D. Palpate the muscle.
A. Apply an opposing force or resistance.
Neck flexion and extension should be:
A. 90 degrees
B. 70 degrees
C. 30 degrees
D. 45 degrees
D. 45 degrees
What is an increased thoracic curvature, common in older adults, called?
A. Scoliosis
B. Lordosis
C. Kyphosis
D. Swayback
C. Kyphosis
Which of the following cranial nerves is assessed by holding a scented object under the patient’s nose?
A. Facial nerve
B. Oculomotor nerve
C. Olfactory nerve
D. Acoustic nerve
C. Olfactory nerve
What are the Snellen and Rosenbaum charts used to assess?
A. Optic nerve
B. Trigeminal nerve
C. Abducens nerve
D. Facial nerve
A. Optic nerve
What does a goniometer measure?
A. Muscle strength
B. Joint stability
C. Cranial nerve function
D. Angles of extension and flexion
D. Angles of extension and flexion
Which of the following findings in a musculoskeletal assessment would be considered abnormal?
A. Nodules
B. Bogginess
C. Symmetry
D. Both A and B
D. Both A and B
What questions can you ask a patient to assess his or her state of consciousness?
A. Ask the patient about his or her thoughts, feelings, and emotions.
B. Ask for the date, his or her name, and the location.
C. Ask the patient to repeat a series of five numbers.
D. Ask the patient to write his or her name and address.
B. Ask for the date, his or her name, and the location.
Which of the following are included in the assessment of mental status?
A. Speech and language
B. Emotional stability
C. Physical appearance and behavior
D. All of the above
D. All of the above
Which of the following actions are part of the assessment of the glossopharyngeal and vagus nerves?
A. Testing the gag reflex
B. Having the patient swallow
C. Touching the patient’s face with dull and sharp objects
D. Both A and B
D. Both A and B
Which test or tests assess accuracy of movement?
A. Finger-to-finger test
B. Finger-to-nose test
C. Heel-to-shin test
D. All of the above
D. All of the above
What should the nurse do if a patient displays staggering or loss of balance during the Romberg test?
A. Give the patient a gentle push to further assess balance.
B. Delay other balance tests.
C. Have the patient stand on one foot with the eyes closed.
D. Have the patient hop on one foot.
B. Delay other balance tests.
How would you assess sensitivity to superficial pain?
A. Touch the patient with the sharp side of a broken tongue blade.
B. Have the patient keep his or her eyes open.
C. Allow 2 seconds between stimuli.
D. Both A and C.
D. Both A and C.
A deep tendon reflex with a normal response is scored as:
A. 0
B. 1+
C. 2+
D. 3+
C. 2+
Which of the following tips will assist with eliciting the patellar and Achilles deep tendon reflexes?
A. Have the patient sit with his or her feet flat on the floor.
B. Have the patient focus on pulling his or her clasped hands apart.
C. Have the patient flex his or her knees at a 45-degree angle.
D. Strike the knee above the patella.
B. Have the patient focus on pulling his or her clasped hands apart.
The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer?
A. Four
B. Two
C. One
D. None
B. Two
The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first?
A. Cross the patient’s arms over his or her chest.
B. Lower the side rails of the bed.
C. Make sure the bed brakes are locked.
D. Fanfold the draw sheet.
C. Make sure the bed brakes are locked.
When turning a patient to place a slide board, where do the assistants stand?
A. At the side of the bed to which the patient will be turned
B. At the side of the bed from which the patient will be turned
C. At the head and foot of the bed
D. At the foot of the bed only
A. At the side of the bed to which the patient will be turned
The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move?
A. Hold the slide board.
B. Pull the draw sheet.
C. Hold the patient’s head stationary.
D. Lock the brakes on the stretcher.
A. Hold the slide board.
After moving a patient from the bed to a stretcher, what will the nurse do next?
A. Lock the wheels on the stretcher.
B. Cover the patient with a blanket.
C. Raise the head of the stretcher if doing so is not contraindicated.
D. Unlock the wheels of the bed.
C. Raise the head of the stretcher if doing so is not contraindicated.
When positioning a hemiplegic patient in the supported Fowler’s position, what is the primary reason a trochanter roll is placed alongside the patient’s legs?
A. To reduce the risk of a fall while the side rails are down
B. To reduce the risk of contracture
C. To control pain
D. To cushion the legs
B. To reduce the risk of contracture
When repositioning a patient, what can the nurse do to prevent the patient’s hips from rolling outward?
A. Apply therapeutic boots to the feet.
B. Place sandbags along the legs.
C. Place a small pillow at the lumbar region of the back.
D. Place a pillow under the calves.
B. Place sandbags along the legs.
To which position would the nurse assist the patient who is experiencing difficulty with breathing?
A. Left lateral recumbent position
B. 30-degree lateral position
C. Fowler’s position
D. Prone position
C. Fowler’s position
The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side?
A. Place a small pillow under the shoulder.
B. Use the affected arm as a guide during rolling.
C. Place a pillow on the abdomen.
D. Place rolled bath blankets along the dependent leg.
C. Place a pillow on the abdomen.
The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned?
A. To position the pillows
B. To keep the spine in alignment
C. To roll the patient as a unit
D. To ease the patient back onto the support pillows
C. To roll the patient as a unit
Inspection of the Chest: Respiration
During inspection, the nurse evaluates the patient’s respirations for rate and rhythm by inspecting the chest wall.
Chest movement should be observed during breathing for _____________________________________________________. The nurse should also note any audible sounds with respiration.
symmetry and use of accessory muscles
Which elements are important for the nurse to assess on inspection of a patient’s chest?
Select all that apply.
Color
Symmetry
Tenderness
Venous patterns
Prominence of ribs
Color
Symmetry
Venous patterns
Prominence of ribs
[The nurse would assess tenderness of the chest on palpation, not inspection.]
During physical assessment, which elements are part of a chest and lung inspection?
Select all that apply.
Symmetry
Temperature
Muscle tone
Use of accessory muscles
Resistance to pressure
Symmetry
Use of accessory muscles
Which structure or landmark should the nurse inspect while assessing the quality of respirations?
Neck
Upper abdomen
Chest wall
Posterior axillary line
Chest wall
To assess tactile fremitus, the nurse asks the patient to :
recite numbers or words.
While the patient does this, the nurse systematically palpates the chest with the palmar surfaces of fingers or the ulnar aspect of a clenched fist, using a firm, light touch. The nurse assesses the area from front to back and side to side and then compares the sides. Tactile fremitus can be best palpated posteriorly and laterally at the level of the bronchial bifurcation.
When palpating the chest, which elements should the nurse note?
Select all that apply.
Sensations
Symmetry
Tactile fremitus
Thoracic expansion
Use of accessory muscles
Sensations
Symmetry
Tactile fremitus
Thoracic expansion
When palpating the chest, which sensations should the nurse note?
Select all that apply.
Crepitus
Color
Grating vibrations
Tactile fremitus
Superficial venous patterns
Crepitus
Grating vibrations
Tactile fremitus
What is being assessed when the nurse asks the patient to recite numbers or words during palpation of the chest?
Symmetry
Tactile fremitus
Thoracic expansion
Tenderness
Tactile fremitus
In which position should the patient be for the nurse to assess the lateral and anterior chest?
Arms at sides
Lying supine
Arms raised overhead
Arm crossed
Arms raised overhead
The nurse percusses the anterior chest to obtain information about which elements of the internal organs?
Select all that apply.
Size
Condition
Function
Location
Developmental state
Size
Condition
Location
When percussing the chest, how should the nurse compare tones?
Bilaterally
Anterior-posterior
Lateral-anterior
Caudal-cranial
Bilaterally
When auscultating the chest, which elements are important for the nurse to note?
Select all that apply.
Symmetry
Tactile fremitus
Vocal resonance
Duration of breath sounds
Unexpected breath sounds
Vocal resonance
Duration of breath sounds
Unexpected breath sounds
In which ways should the nurse characterize the breath sounds heard on auscultation of the chest and lungs?
Select all that apply.
Pitch
Intensity
Tone
Quality
Duration
Pitch
Intensity
Quality
Duration
For which elements of vocal resonance should the nurse auscultate?
Select all that apply.
Nasal quality to spoken words
Change in accent of spoken words
Increased loudness of spoken words
Increased loudness of whispered words
Absence of the ability to hear spoken words
Nasal quality to spoken words
Increased loudness of spoken words
Increased loudness of whispered words
During inspection, which peripheral structures provide clues about the patient’s cardiac health?
Select all that apply.
Lips
Nails
Hair
Fingers
Alae nasi
Lips
Nails
Fingers
Alae nasi
In which position should a patient be when the nurse is percussing the back?
Lying supine with arms at sides
Prone position with arms at sides
Standing erect with arms raised above head
Leaning forward with arms crossed and neck flexed
Leaning forward with arms crossed and neck flexed
Which element is being assessed when the nurse auscultates the chest?
Rib location
Liver location
Diaphragm size
Lung condition
Lung condition
On inspection of the chest and lungs, the nurse should evaluate which features of the patient’s respirations?
Tone
Rate
Rhythm
Amplitude
Audible sounds
Rate
Rhythm
Audible sounds
What is a nurse assessing in relation to the trachea when he/she uses palpation during a thorough chest and lung examination?
Resonance
Location
Symmetry
Tactile fremitus
Location
During examination of the chest and lungs, the nurse would palpate posteriorly and laterally at the level of the bronchial bifurcation to assess the quality of __________________.
tactile fremitus
The Point of Maximal Impulse PMI is located at the ______ of the heart, which is at the fifth intercostal at the midclavicular line
apex
Some basic equipment is required to assess the ______. Necessary equipment includes:
Stethoscope with bell and diaphragm
Marking pencil
Centimeter ruler
heart
What initial step should be performed when assessing the heart?
Auscultation
Inspection
Palpation
Percussion
Inspection
Inspection is the initial step in the examination process and is used to identify the contour of the anterior chest wall and the location of the point of maximal impulse (PMI).
The nurse is performing a cardiac assessment on a patient and is attempting to inspect the apical pulse. The nurse understands that the best location to visualize the apical pulse is:
Second intercostal space to the left of the sternum
Second intercostal space to the right of the sternum
Fifth intercostal space at the midclavicular line
Fifth intercostal space to the left of the sternum
Fifth intercostal space at the midclavicular line
The nurse is assessing a patient with jugular venous distention in the supine position. The nurse knows that the best way to assess jugular venous distention is to:
Measure the pressure in centimeters
Locate the internal jugular vein
Identify the highest point of pulsation
Raise the head of the bed
Raise the head of the bed
Raising the head of the bed helps to identify the external jugular vein, which leads to a better visualization of the internal jugular vein
When palpating the base of the heart, the hand of the nurse will be placed at which location?
Second intercostal space to the right of the sternum
Second intercostal space to the left of the sternum
Fifth intercostal space to the left of the midclavicular line
Fifth intercostal space to the left of the sternal border
Second intercostal space to the left of the sternum
The nurse is attempting to palpate the apical pulse of a patient with heart-related symptoms. The nurse understands that the apical pulse is most easily palpated during which part of the cardiac cycle?
Contraction of the left ventricle
Stimulation of the sinoatrial (SA) node
Relaxation of the left ventricle
Contraction of the tricuspid valve
Contraction of the left ventricle
Why has the chest x-ray made the technique of percussion optional?
The patient can be in any position to have a chest x-ray.
A chest x-ray can offer more precise information.
A chest x-ray is preferred by women.
A chest x-ray is less time consuming.
A chest x-ray can offer more precise information.
For which patients would the nurse expect distorted findings while percussing the heart?
Select all that apply.
A body builder
An overweight patient
A patient with leukemia
A malnourished patient
A patient with pericardial effusion
A body builder
An overweight patient
A patient with pericardial effusion
_____________ _________, an extra systolic sound heard best when the patient leans forward and the heart is closer to the chest wall.
Ejection click
_______________, a scraping sound heard when there is inflammation in the heart tissue.
Friction rub
Mitral _______ , heard when a thickened, diseased mitral valve opens.
snaps
____________, extra, low-pitched heart sounds that can be defined as either S3 (rapid filling of ventricle with blood at the beginning of diastole) or S4 (atrial contraction resulting in ejection of blood into a ventricle that cannot expand), depending on when during the cardiac cycle it is heard.
Gallops
Select the location for auscultation of the aortic area.
Second right intercostal space to the right of the sternal border
Second left intercostal space to the left of the sternal border
Fourth left intercostal space along the lower left sternal border
Fifth intercostal space at the midclavicular line
Second right intercostal space to the right of the sternal border
Using the diaphragm of the stethoscope, the nurse will begin auscultating the heart in which anatomical area of a typical patient?
Aortic
Pulmonic
Tricuspid
Mitral
Mitral
The point of maximal impulse (PMI) is located in the mitral area, which is the apex of the heart, and can be easily identified in most patients. This is the usual location at which to begin auscultation of the heart. From the apex, the nurse would follow a systematic sequence.
The second heart sound (S2) should be assessed at which location?
Aortic area
Mitral area
Tricuspid area
Second pulmonic area
Aortic area
Atrial contraction resulting in ejection of blood into a ventricle that cannot expand
S4
Closure of the pulmonic and aortic valves
S2
Early, rapid filling of the ventricle with blood at the very beginning of diastole
S3
Blood flow across an incompetent valve
murmurs
What term identifies a split sound heard during auscultation of the heart?
Fixed
Gallop
Murmur
Regurgitation
fixed (splitting)
While inspecting the chest, the nurse observes unusual chest movements. Which assessment technique should the nurse perform next?
Auscultation
Inspection
Palpation
Percussion
Palpation
Identify the area of the body where the nurse observes for lifts and heaves.
Precordium
Right internal jugular vein
Epigastric region
Carotid artery
Precordium
Describe how the nurse uses palpation to ensure the identification of the first heart sound (S1).
Using two fingers over the popliteal artery
Using two fingers over the aortic and pulmonic valves
Counting the beats from the popliteal artery and radial artery
Placing the hand over the carotid artery and point of maximal impulse (PMI)
Placing the hand over the carotid artery and point of maximal impulse (PMI)
Describe how the nurse uses palpation to identify dextrocardia.
Locate the point of maximal impulse (PMI)
Observe for presence of cyanosis
Locate the borders of the heart
Identify the direction of the thrill
Locate the point of maximal impulse (PMI)
The nurse is palpating the base of the heart and identifies a fine rushing vibration. The nurse correctly documents this symptom as what?
Pericardial friction rub
Murmur
Gallop
Opening snap
Murmur
Which statement describes the limitations of using the percussion technique in physical examination?
Select all that apply.
Percussion is difficult to learn.
The percussion technique is not sensitive enough to detect changes in heart size.
The heart conforms to the chest’s shape, making it difficult to assess heart size.
Fluid or air can distort findings.
Enlargement of the right ventricle occurs laterally.
The heart conforms to the chest’s shape, making it difficult to assess heart size.
Fluid or air can distort findings.
Using percussion, the nurse identifies the cardiac border by a change from a _____ to a _____ note.
Flat; dull
Resonant; dull
Hyperresonant; tympanic
Split; fixed
Resonant; dull
The nurse is having trouble auscultating the apical impulse of an obese patient. Which action by the nurse would improve this assessment?
Have the patient lie supine.
Have the patient lean forward.
Tell the patient to take a deep breath and hold it.
Place the stethoscope over the epigastrum.
Have the patient lean forward.
Identify the area where the mitral valve should be auscultated.
Second intercostal space to the left of the sternum
Second intercostal space to the right of the sternum
Fourth intercostal space along the lower left sternum
Fifth intercostal space at the midclavicular line
Fifth intercostal space at the midclavicular line
The nurse is auscultating heart sounds of a patient with heart-related symptoms. The nurse understands that the bell of the stethoscope is best used for auscultating what heart sounds?
High-pitched heart sounds
Low-pitched heart sounds
High-pitched heart murmurs
Closure of the tricuspid and mitral valves
Low-pitched heart sounds
The nurse assesses a patient with abnormal heart sounds. This symptom is correctly documented as the third heart sound (S3) because it is low-pitched and located at which area of the heart?
Apex
Entire pericardium
Second right intercostal space
Second left intercostal space
Apex
When auscultating the heart sounds, the nurse makes note of what qualities of the auscultated sounds?
Select all that apply.
Pitch
Rhythm
Location
Timing
Frequency
Pitch
Rhythm
Location
Timing
Why is it vital to identify the baseline rate and rhythm of the heart?
Select all that apply.
To identify tachycardia or bradycardia
To measure cardiac output
To identify the first heart sound (S1)
To identify dysrhythmias
To identify tachycardia or bradycardia
To identify dysrhythmias
During assessment of the peripheral vascular system, it is important for the nurse to assess temperature and sensation, as well as the 3 Ps:
_________
First symptom of peripheral arterial disease
Referred to as claudication
Dull ache in the leg(s) with muscle fatigue and cramps
Usually appears during exercise (walking longer distances, climbing stairs)
Typically relieved by rest
________
Color change of the skin
Note if skin is pale or cyanotic
_________
Strong, weak, or absent
Pain
Pallor
Pulse
What characteristic of the pulse can be described as smooth, rounded, or dome-shaped?
Contour
Amplitude
Symmetry
Rate and rhythm
Contour
Which sound, auscultated over the neck, is heard at the medial end of the clavicle and anterior border of sternocleidomastoid muscle?
Venous hum
Cardiac bruit
Temporal bruit
Femoral bruit
Venous hum
When assessing for peripheral arterial disease, the nurse should assess for signs and symptoms related to which aspects of decreased blood flow?
Select all that apply.
Pain
Pallor
Poor movement
Muscle cramps
Pain at rest
Pain
Pallor
Muscle cramps
When assessing for peripheral arterial disease, what should the nurse note about the condition of the patient’s skin?
Select all that apply.
Color
Temperature
Hair growth
Atrophy
Cyanosis
Color
Temperature
Atrophy
Cyanosis
Which characteristics suggest deep vein thrombosis (DVT)?
Select all that apply.
Leg lesion
Constant calf pain
Tenderness over a vein
Swelling to one extremity
Calf pain with dorsiflexion of the foot
Tenderness over a vein
Swelling to one extremity
Calf pain with dorsiflexion of the foot
The amplitude of a pulse can be described on a scale of 0-4. Which number represents a bounding, aneurysmal pulse?
4
Which pulse characteristic can be assessed by comparing the strength of the upper extremity pulses with the strength of the lower extremity pulses?
Heart rate
Symmetry
Waveform
Amplitude
Symmetry
Which pulse characteristic should the nurse assess when looking for evidence of local obstruction?
Rate
Rhythm
Bruits
Contour
Bruits
When assessing for peripheral arterial disease, which pulse characteristics should the nurse evaluate after assessing the patient’s pain?
Pulse rate
Pulse rhythm
Pulse strength
Loss of core body warmth
Pulse strength
The nurse is using capillary refill time to assess the severity of arterial insufficiency. After blanching the nail bed and releasing the pressure, what is the next step the nurse performs?
Assessing jugular vein distention
Recording the patient’s pulse
Taking the patient’s blood pressure
Counting the time for the skin to return to normal
Counting the time for the skin to return to normal
What action should the nurse take to help distinguish jugular pulsations from carotid pulsations?
Palpate the carotid pulse
Have the patient stand up during the assessment
Ask the patient to hold his or her breath during the assessment
Hold pressure for 10 seconds while the patient is lying at 45 degrees
Palpate the carotid pulse
On assessment of a patient’s leg for edema, the nurse observes deep pitting lasting 2-5 minutes and gross distortion of the affected leg. Which grade of edema should the nurse document?
1+
2+
3+
4+
4+
For which signs of venous obstruction leading to insufficiency should the nurse expect to assess?
Select all that apply.
Fatigue
Hair loss
Homans’ sign
Swelling and tenderness
Engorgement of superficial veins
Hair loss
Homans’ sign
Swelling and tenderness
Engorgement of superficial veins
Which characteristics of the lymph nodes would be assessed on palpation?
Select all that apply.
Size
Color
Warmth
Mobility
Tenderness
Size
Warmth
Mobility
Tenderness
Which characteristics should be noted when the external areas where lymph nodes exist are inspected?
Select all that apply.
Color
Swelling
Tenderness
Temperature
Site enlargement
Color
Swelling
Site enlargement
When palpating lymph nodes in the neck, which structure serves as a dividing line between the anterior and posterior triangles of the neck?
Anterior border of the trapezius muscle
Posterior border of the trapezius muscle
Anterior border of the sternocleidomastoid muscle
Posterior border of the sternocleidomastoid muscle
Anterior border of the sternocleidomastoid muscle
In which area of the body are the inguinal lymph nodes located?
Arms
Axilla
Groin
Breast
Groin
Where are the epitrochlear lymph nodes located?
Legs
Arms
Neck
Breast
Arms
Where are the popliteal lymph nodes located?
Legs
Neck
Axilla
Breast
Legs
Which is a correct method used when palpating lymph nodes?
Select all that apply.
Begin with light pressure
Begin with heavy pressure
Identify all nodes with a marking pencil
Focus on palpating the superficial nodes
Begin with light pressure
Where are the brachial lymph nodes located?
Legs
Arms
Neck
Breast
Arms
Which lymph nodes in the upper extremities are accessible to inspection and palpation?
Sublingual
Epitrochlear
Anterior pectoral nodes
Retropharyngeal nodes
Epitrochlear
When inspecting the skin of the abdomen, which surface characteristics would the nurse observe?
Select all that apply.
Striae
Temperature
Lesions and scars
Tautness
Venous return
Striae
Lesions and scars
Tautness
Venous return
At which region of the abdomen would the nurse palpate the pancreas?
Umbilical
Epigastric
Left hypochondriac
Right inguinal
Epigastric
On auscultation, which elements of a patient’s bowel sounds should be assessed?
Select all that apply.
Frequency
Character
Number
Tone
Pitch
Frequency
Character
Over which abdominal structures should the nurse auscultate for friction rubs?
Select all that apply.
Heart
Spleen
Lungs
Liver
Colon
Liver
Spleen
The nurse should percuss the abdomen to obtain which information?
Select all that apply.
Presence of masses
Presence of ascites
Presence of bowel sounds
Presence of gastric distention
Size of the organs
Presence of masses
Presence of ascites
Presence of gastric distention
Size of the organs
Which abdominal structures are assessed through percussion?
Select all that apply.
Spleen
Pancreas
Liver
Kidneys
Lungs
Spleen
Liver
Kidneys
Which type of palpation is necessary to delineate abdominal organs and detect masses?
Light
Moderate
Deep
Bimanual
Deep
Liver
Which test should be performed if the nurse suspects appendicitis?
Ballottement
Obturator muscle test
McBurney sign
Iliopsoas muscle test
Iliopsoas muscle test
How should the nurse assess for ascites?
Select all that apply.
Look for a fluid wave
Auscultate for fluid
Identify shifting dullness on percussion
Palpate for a mass
Inspect for pulsations
Look for a fluid wave
Identify shifting dullness on percussion
Which test should be performed if the nurse suspects a ruptured appendix?
Ballottement
Obturator muscle test
McBurney sign
Iliopsoas muscle test
Obturator muscle test
When inspecting the surface of the abdomen, which aspect of contour should be assessed?
Skin texture
Visibility of pubic bones
Abdominal profile from naval to lateral side
Abdominal profile from rib margin to pubis
Abdominal profile from rib margin to pubis
Which region of the body is assessed in the upper middle region (region 1) of the abdomen?
Epigastric
Which elements of a patient’s abdomen should be assessed on inspection?
Select all that apply.
Movement
Contour
Bowel sounds
Skin temperature
Surface characteristics
Movement
Contour
Surface characteristics
Over which abdominal region should the nurse auscultate to assess for a venous hum?
Umbilical
Left hypochondriac
Right inguinal
Epigastric
Epigastric
Over which region should the nurse auscultate to assess for bruits?
Umbilical
Left hypochondriac
Right inguinal
Epigastric
Epigastric
At which abdominal landmark would the nurse begin percussing the liver?
Umbilical ring
Costal margin
Right midclavicular line
Superior margin of os pubis
Right midclavicular line
At which abdominal area would the nurse begin percussing the spleen?
Anterosuperior iliac spine
Anterior to the midclavicular line
Posterior to the left midaxillary line
Right of the xiphoid process of the sternum
Posterior to the left midaxillary line
Liver size can be assessed through percussion by evaluating which characteristics?
Select all that apply.
Liver weight
Liver tone
Liver span
Liver circumference
Extent of liver projection
Liver span
Extent of liver projection
On palpation, which features of detected masses can be assessed?
Select all that apply.
Size
Shape
Pulsation
Mobility
Surface texture
Movement with respiration
Size
Shape
Pulsation
Mobility
Movement with respiration
Which structure is palpated below the liver margin at the lateral border of the rectus abdominis muscle?
Spleen
Pancreas
Gallbladder
Left kidney
Gallbladder
Which signs indicate peritoneal inflammation on assessment?
Boggy abdomen on palpation
Rebound tenderness
Dull note on percussion
Pulsations on inspection
McBurney sign
Rebound tenderness
Which tool is the most widely accepted tool for assessing acute appendicitis?
Ohmann score
Alvarado score
Murphy score
The Pediatric appendicitis score
Alvarado score
Ballottement is a technique used to assess a _______
mass
Friction rubs are auscultated over the __________ region
epigastric
Kidney
____________ Data - Health History Questions
-Cough
- Shortness of breath
- Chest pain with breathing
-History of respiratory infections
-Smoking history
- Environmental exposure
- Self-care behaviors
Subjective
_____________ Data – Posterior Chest
Inspection of Thoracic cage
◦ Shape and configuration of chest wall
◦ Anteroposterior/transverse diameter
◦ Position of person
◦ Skin color and condition
Palpate
- Symmetric expansion
- Tactile (or vocal) fremitus
◦ Technique
◦ Factors that affect normal intensity of tactile fremitus
-Palpate the entire chest wall
Percuss
- Predominant note over lung fields
- Diaphragmatic excursion
Auscultate
Breath sounds - Expected
◦ Bronchial breath sounds
◦ Bronchovesicular breath sounds
◦ Vesicular breath sounds
Adventitious – Not expected
◦ Crackles (rales)
◦ Wheezes
◦ Pleural friction rub
Objective
Abnormal Findings - Adventitious Lung Sounds
__________ (formerly called rales)
◦ Fine
◦ Coarse
___________
◦ High pitched
◦ Low Pitched
Pleural friction rub
Crackles (formerly called rales)
◦ Fine
◦ Coarse
Wheezes
◦ High pitched
◦ Low Pitched
Pleural friction rub
__________ Data – Anterior Chest
Inspect
- Shape and configuration of chest wall
- Facial expression
-Level of consciousness
-Skin color and condition
- Quality of respirations
- Rib interspaces
- Accessory muscles
Palpate
- Symmetric chest expansion
- Tactile fremitus
- Palpate the anterior chest wall
Percuss
- Predominant note over lung fields
- Borders of cardiac dullness
Auscultate
-Breath sounds
- Abnormal breath sounds
-Adventitious sounds
Objective
Abnormal Findings Respiration Patterns
- Tachypnea
-Bradypnea - Hyperventilation
-Hypoventilation - Cheyne-Stokes respirat
- Tachypnea
-Bradypnea - Hyperventilation
-Hypoventilation - Cheyne-Stokes respirat
During an examination of the anterior thorax, the nurse recalls that the trachea bifurcates anteriorly at the:
1. costal angle.
2. sternal angle.
3. xiphoid process.
4. suprasternal notch.
- sternal angle.
The primary muscles of respiration include the:
1.diaphragm and intercostals.
2.sternomastoids and scaleni.
3.trapezius and rectus abdominis.
4.external obliques and pectoralis major.
1.diaphragm and intercostals.
The nurse knows that percussion over an area of atelectasis in the lungs would reveal:
1.dullness.
2.tympany.
3.resonance.
4.hyperresonance.
1.dullness.
The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:
1.increased thoracic expansion.
2.decreased mobility of the thorax.
3.a decreased anteroposterior diameter.
4.bronchovesicular breath sounds throughout the lungs
2.decreased mobility of the thorax.
Anteriorly, there are 2 lobes of lung on the ______
and 3 lobes on the ______
But on the back, only 2 lobes on each side
Anteriorly, there are 2 lobes of lung on the left
and 3 lobes on the right
But on the back, only 2 lobes on each side
An anteroposterior-to-transverse diameter of 1:1 or “barrel chest” is seen in individuals with chronic obstructive pulmonary disease because of _____________ of the lungs.
hyperinflation
The nurse is aware that tactile fremitus is produced by:
1. moisture in the alveoli.
2.air in the subcutaneous tissues.
3.sounds generated from the larynx.
4.blood flow through the pulmonary arteries.
3.sounds generated from the larynx.
Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations.
During palpation of the anterior chest wall, the nurse notes a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:
1.tactile fremitus.
2.crepitus.
3.friction rub.
4.adventitious sounds.
2.crepitus.
Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:
1.adventitious sounds and limited chest expansion.
2.increased tactile fremitus and dull percussion tones.
3.muffled voice sounds and symmetrical tactile fremitus.
4.absent voice sounds and hyperresonant percussion tones.
3.muffled voice sounds and symmetrical tactile fremitus.
Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, no adventitious sounds, and muffled voice sounds.
Duration of breath sounds:
Bronchial
Bronchiovesicular
Vesicular
Internal anatomy (_________)
◦ Solid viscera
Liver
Pancreas
Spleen
Adrenal glands
Kidneys
Ovaries
Uterus
◦ Hollow viscera
Stomach
Gallbladder
Small intestine
Colon
Bladder
◦ Solid viscera
Liver
Pancreas
Spleen
Adrenal glands
Kidneys
Ovaries
Uterus
◦ Hollow viscera
Stomach
Gallbladder
Small intestine
Colon
Bladder
Abdominal wall divided into four ___________
◦ Right upper (RUQ)
◦ Left upper (LUQ)
◦ Right lower (RLQ)
◦ Left lower (LLQ)
quadrants
____________ data- Abdomen - Health history
Appetite
Dysphagia
Food intolerance
Abdominal pain
Nausea/vomiting
Bowel habits
Abdominal history
Medications
Nutritional assessment
Subjective
__________ data- physical exam- Abdomen
Inspect the abdomen
- Contour
-Symmetry
-Umbilicus
- Skin
-Pulsation or movement
- Hair distribution
-Demeanor
Auscultate the abdomen
-Bowel sounds
- Vascular sounds (bruits)
Percuss the abdomen
- General tympany
- Liver span
- Splenic dullness
- Costovertebral angle
tenderness
Palpate
-Measures to enhance muscle relaxation
- Light palpation
- Deep palpation
- Bimanual palpation
- Normally palpable structures
- Liver
◦ Usual technique
◦ Hooking technique
- Spleen
- Kidneys
- Aorta
Objective
Abnormal findings- Abdominal
-Obesity
-Air or gas
-Ascites
-Ovarian cyst
-Pregnancy
-Feces
-Tumor
-Umbilical hernia
-Epigastric hernia
- Incisional hernia
-Obesity
-Air or gas
-Ascites
-Ovarian cyst
-Pregnancy
-Feces
-Tumor
-Umbilical hernia
-Epigastric hernia
- Incisional hernia
___________ bowel sounds
Hypoactive bowel sounds
-bowel sounds slow
Hyperactive bowel sounds
-very noisy
Abnormal
When the patient reports that a certain abdominal spot is tender, it is best to:
A.palpate that spot last, to prevent pain from interfering with the rest of the examination.
B.palpate that spot first, to avoid prolonging the patient’s anticipation.
C.avoid that spot entirely, as other clinicians are going to palpate it after you.
D.palpate in the same order as you always would, to avoid missing something because you broke your routine.
A.palpate that spot last, to prevent pain from interfering with the rest of the examination.
Chamber and valves of the heart
Chambers
◦ Atria—right and left
◦ Ventricles—right and left
Valves
◦ Atrioventricular
- Tricuspid
-Mitral
◦ Semilunar
- Pulmonic
- Aortic
Chambers
◦ Atria—right and left
◦ Ventricles—right and left
Valves
◦ Atrioventricular
- Tricuspid
-Mitral
◦ Semilunar
- Pulmonic
- Aortic
__________ exam- neck vessels
Carotid arteries
◦ Palpate
◦ Auscultate for bruit
Jugular veins
◦ Inspect the jugular venous pulse
Precordium
-Inspect the anterior chest
- Palpate the apical impulse
- Palpate across the precordium
Auscultate the heart sounds
- Identify auscultatory areas
◦ Note the rate and rhythm
- Sinus arrhythmia
- Pulse deficit
◦ Identify S1 and S2
- S1 is louder than S2 at the apex
- S2 is louder than S1 at the base
- S1 coincides with carotid artery pulse
- S1 coincides with R wave on electrocardiogram
◦ Listen to S1 and S2 separately
◦ Listen for extra heart sounds
◦ Listen for murmurs
Physical
Which of the following individuals is likely at the highest risk for orthostatic hypotension?
A 50-year-old man with pneumonia
B. A 4-year-old patient with cystic fibrosis
C. A 20-year-old woman who smokes and takes oral contraceptives
D. An 86-year-old woman with mild ankle edema
D. An 86-year-old woman with mild ankle edema
Lymphatics
- Right lymphatic duct
- Thoracic duct
- Functions of the lymphatic system
- Lymph nodes
- Related organs to lymphatic system
______________________ of lymph system: immune function; hold on to fluids and proteins, absorbs fat from the gut
3 general purposes
_____________ data- lymphatics
- Leg pain or cramps
- Skin changes on arm or legs
- Swelling
- Lymph node enlargement
-Medications
Subjective
___________ data- lymphatics- physical exam
Arms—Inspect and palpate
Skin
Profile sign
Capillary refill
Symmetry
Radial pulse
Ulnar pulse
Brachial pulse
Legs—Inspect and palpate
Skin and hair
Symmetry
Temperature
Calf muscle
Inguinal lymph nodes
Femoral pulse
Popliteal pulse
Posterior tibial pulse
Dorsalis pedis pulse
Pretibial edema
Leg veins
◦ Assess while patient stands
◦ Manual compression test
Additional techniques
◦ Color changes
◦ Ankle-brachial index (ABI)
◦ Doppler ultrasonic stethoscope
Objective
What is the relevant variable when discussing claudication with a patient?
A. Related foods
B. Distance
C. Blood glucose
D. Emotional state
B. Distance
____________ - distance a patient walks before experiencing pain in lower extremities [clue to level of peripheral vascular disease]
Claudication
[pain goes away with rest]
Grading pulses
0 - no pulse
1- weak
2- easily palpable
3- strong
4- bounding
The sac that surrounds and protects the heart is:
Pericardium
The component of the conduction system referred to as the pacemaker of the heart is:
SA node (sinoatrial node)
The electric stimulus of the cariac cycle follows which sequence?
SA node
AV node
Bundle of His
Bundle branches
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
Elevated pressure related to heart failure.
it is important to document the heart sounds in precisely the correct locations to accurately correlate those sounds with particular valves.
T or F?
False
Direction of blood flow
Cardiac cycle
◦ Diastole - relaxation & filling of heart
◦ Systole - ejection of blood out of heart
◦ Events in the right and left sides
Heart sounds
◦ First heart sound - s1 Lub - closure of trisucpid & mitral valves
◦ Second heart sound -s1 Dub - closure of aortic and pulmonic valves
◦ Effect of respiration
Cardiac cycle
◦ Diastole - relaxation & filling of heart
◦ Systole - ejection of blood out of heart
◦ Events in the right and left sides
Heart sounds
◦ First heart sound - s1 Lub - closure of trisucpid & mitral valves
◦ Second heart sound -s1 Dub - closure of aortic and pulmonic valves
◦ Effect of respiration
__________ - turbulence heard around valves, usually blowing or swishing sound
Murmurs
Pumping ability
Cardiac _________ : measures how much blood the heart pumps in a minute.
Clinically assessed using tests like echocardiograms or cardiac catheterization.
___________ : how much the heart fills with blood before it pumps.
Clinically assessed by looking at central venous pressure (CVP) using a catheter.
____________: This is the pressure the heart has to push against to pump blood out.
Clinically assessed by measuring blood pressure.
Cardiac Output: measures how much blood the heart pumps in a minute.
Clinically assessed using tests like echocardiograms or cardiac catheterization.
Preload: how much the heart fills with blood before it pumps.
Clinically assessed by looking at central venous pressure (CVP) using a catheter.
Afterload: This is the pressure the heart has to push against to pump blood out.
Clinically assessed by measuring blood pressure.
___________ is when someone has trouble breathing while lying down and needs to sit up to breathe comfortably.
Orthopnea
-Omegaly
as in splenomegaly means:
Enlarged
[Enlarged spleen]
Auscultation sites for the heart - mnemonic
APE TO MAN
Aortic point
Pulmonic point
Erb’s point
Tricuspid point
Mitral valve point.
If a patient has elevated body temperature, what happens to pulse and respirations? blood pressure?
Pulse and respiration increases
blood pressure does not increase
Ascites is a condition in which _______ collects in spaces within your _________.
Ascites is a condition in which fluid collects in spaces within your abdomen
Ascites is caused by:
liver failure
Identify A, B, C
A- Pericardium
B- Base
C- Apex
Identify A, B, C, D, E
A- Aorta
B- Left atrium
C- Aortic valve
D- Mitral (AV) valve
E- Left ventricle
Identify F, G, H, I, J, K
F- Right ventricle
G- Tricuspid (AV) Valve
H- Right atrium
I- Pulmonic valve
J- Pulmonary artery
K- Superior vena cava
Dyspnea:
Difficult or labored breathing.
Shortness of breath
Cycle of blood flow
It starts in the ____________ >
through the _________ valve to the __________ >
through the _________ valve to the ______ >
blood picks up oxygen and returns to the ____________ >
through the _________ valve to the __________ >
through the _______ valve into the _______ > rest of the body >
deoxygenated blood returns to the ____________ > cycle begins again.
It starts in the right atrium >
through the tricuspid valve to the right ventricle >
through the pulmonary valve to the lungs >
blood picks up oxygen and returns to the left atrium >
through the mitral valve to the left ventricle >
through the aortic valve into the aorta > rest of the body >
deoxygenated blood returns to the right atrium > cycle begins again.
Mnemonic for blood flow via valves in order
“Toilet Paper My Ass”
Tricuspid
Pulmonary
Mitral
Aortic
The Point of Maximal Impulse PMI is located at the apex of the heart, which is at the _____________ at the midclavicular line
fifth intercostal at the midclavicular line
The heart’s electrical system controls the heartbeat.
It starts in the _________ , located in the right atrium, which acts as the heart’s natural pacemaker by generating an electrical signal.
This signal causes the ______ (upper chambers) to contract, pushing blood into the ventricles (lower chambers).
The signal then reaches the _________ , which slows it down slightly to allow the ventricles to fill with blood.
From the AV node, the signal travels through the ___________ and splits into the right and left bundle branches, carrying it to the ventricles.
Finally, the signal spreads through the ___________, causing the ventricles to contract and pump blood out to the lungs and the rest of the body.
The heart’s electrical system controls the heartbeat.
It starts in the SA node, located in the right atrium, which acts as the heart’s natural pacemaker by generating an electrical signal.
This signal causes the atria (upper chambers) to contract, pushing blood into the ventricles (lower chambers).
The signal then reaches the AV node, which slows it down slightly to allow the ventricles to fill with blood.
From the AV node, the signal travels through the Bundle of His and splits into the right and left bundle branches, carrying it to the ventricles.
Finally, the signal spreads through the Purkinje fibers, causing the ventricles to contract and pump blood out to the lungs and the rest of the body.
Identify A, B, C, D, E, F
A- clavicle
B- 2nd intercostal space
C- Suprasternal notch
D- Body of sternum
E- Xiphoid process
F- Costal angle
identify
scoliosis
identify
Kyphosis
Tachypnea
abnormally rapid breathing
Bradypnea
abnormally slow breathing rate
Hyperventilation
deep and fast breathing
Hypoventilation
breathing that is too shallow or too slow to meet the needs of the body
Cheyne-Stokes respirations
atypical pattern of breathing involving deep breathing followed by shallow breathing
identify all parts
know lung anatomy
Dull vs resonant sounds when percussing abdomen
A dull sound indicates the presence of a solid mass under the surface. Denseness - organ.
A more resonant sound indicates hollow, air-containing structures. or gas.
identify all
A- spleen
B- Stomach
C- small intestine
D- Bladder
E- appendix
F- Gallbladder
G- Liver
Review deep internal anatomy of abdomen
identify all
what is this?
Striae
_________ is a medical term for difficulty swallowing.
Dysphagia
Nursing Diagnosis - PES
Problem
Etiology
Symptoms
P (Problem): Nursing diagnosis label from the NANDA-I list.
E (Etiology): r/t phrase or etiology.
S (Symptoms): Defining characteristics observed during assessment.
Example using PES System:
Problem: Deficient Knowledge
Etiology: r/t unfamiliarity with nursing process information
Symptoms: aeb verbalization of lack of understanding
Aging leads to isolated _______ hypertension due to stiffening and thickening of large arteries (arteriosclerosis).
Left ventricular wall thickness increases as an adaptive response to vascular stiffening, increasing workload on the heart.
_________ blood pressure may decrease after age 50, increasing pulse pressure.
Aging leads to isolated systolic hypertension due to stiffening and thickening of large arteries (arteriosclerosis).
Left ventricular wall thickness increases as an adaptive response to vascular stiffening, increasing workload on the heart.
Diastolic blood pressure may decrease after age 50, increasing pulse pressure.
Resting heart rate remains unchanged with aging.
Cardiac output at rest does not change, but there’s a decreased ability to augment output with exercise.
__________ maximum heart rate and sympathetic response with aging affect exercise tolerance.
Resting heart rate remains unchanged with aging.
Cardiac output at rest does not change, but there’s a decreased ability to augment output with exercise.
Diminished maximum heart rate and sympathetic response with aging affect exercise tolerance.
Aging increases the prevalence of supraventricular and ventricular __________ .
Ectopic beats are common and can compromise cardiac function, especially in diseased hearts.
Tachydysrhythmias may be poorly tolerated due to myocardial changes and impaired diastolic filling.
Aging increases the prevalence of supraventricular and ventricular dysrhythmias.
Ectopic beats are common and can compromise cardiac function, especially in diseased hearts.
Tachydysrhythmias may be poorly tolerated due to myocardial changes and impaired diastolic filling.
Describe signs and symptoms of heart failure
Signs and symptoms of heart failure come from two basic mechanisms:
(1) heart’s inability to ____________________ to meet the metabolic demands of the body
(2) the kidney’s _____________________ of abnormal retention of sodium and water to compensate for the decreased cardiac output. This increases blood volume and venous return, which causes further congestion.
(1) heart’s inability to pump enough blood to meet the metabolic demands of the body
(2) the kidney’s compensatory mechanisms of abnormal retention of sodium and water to compensate for the decreased cardiac output. This increases blood volume and venous return, which causes further congestion.
Lungs with aging
Thoracic Mobility: _________ due to calcification of costal cartilages.
Muscle Strength: Respiratory muscles _______ from age 50 onward.
Lung Elasticity: ______, making lungs stiffer and less compliant.
Airway Function: Small airway closure __________, reducing vital capacity and increasing residual volume.
Histologic Changes: Loss of ________reduces gas exchange surface area.
Ventilation: Lung bases become less _________, increasing dyspnea risk during exertion.
Thoracic Mobility: Decreases due to calcification of costal cartilages.
Muscle Strength: Respiratory muscles weaken from age 50 onward.
Lung Elasticity: Decreases, making lungs stiffer and less compliant.
Airway Function: Small airway closure increases, reducing vital capacity and increasing residual volume.
Histologic Changes: Loss of alveoli reduces gas exchange surface area.
Ventilation: Lung bases become less ventilated, increasing dyspnea risk during exertion.
__________ are discontinuous popping sounds heard over inspiration
_________ are continuous musical sounds heard mainly over expiration
Crackles AKA rales are discontinuous popping sounds heard over inspiration
wheezes AKA Rhonchi are continuous musical sounds heard mainly over expiration
Most (but not all) cases of COPD are caused by ____________
smoking
Chronic obstructive breathing pattern
Normal inspiration and prolonged expiration to overcome increased airway resistance
In a person with chronic obstructive lung disease, any situation calling for increased heart rate (exercise) may lead to dyspneic episode (air trapping) because the person does not have enough time for full expiration.
Cardiac Output measures : ?
how much blood the heart pumps in a minute.
Preload:
volume of blood coming into heart
Afterload:
pressure/ resistance the heart works against to pump blood into body
Arteries carry blood:
away from the heart
Veins carry blood:
back to the heart
[lower pressure]
For someone who has left ventricular hypertrophy, where would the apical pulse be heard?
5th intercostal space at the mid-axillary line
why? Left ventricle is larger, so readings would be closer to the side
______1_____: high pressure, tough, strong, elastic,
______2______: generally larger diameter, low pressure, capacitance vessel (high volume), intraluminal valves. Moves d/t muscles and respiratory system
1- Arteries
2- Veins
Pulse __________ : a heartbeat marked by two beats close together with a pause following each pair of beats
Pulse __________ : a pulse pattern in which there is alternating (beat-to-beat) variability of pulse strength
Pulse ___________ : an exaggerated fall in a patient’s blood pressure during inspiration by greater than 10 mm Hg
Pulse bigeminus: a heartbeat marked by two beats close together with a pause following each pair of beats
Pulse alternans: a pulse pattern in which there is alternating (beat-to-beat) variability of pulse strength
Pulse paradoxus: an exaggerated fall in a patient’s blood pressure during inspiration by greater than 10 mm Hg
What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?
A. Rapid, thready pulse
B. Distended jugular veins
C. Elevated hematocrit level
D. Increased serum sodium level
B. Distended jugular veins
The direction of the blood flow through the heart is best described by which of these?
A. Vena cava, RA, RV, Lungs, Pulmonary Artery, LA, LV
B. RA, RV, Pulmonary Artery, Lungs, Pulmonary Vein, LA, LV
C. Aorta, RA, RV, Lungs, Pulmonary Vein, LA, LV, Vena cava
D. RA, RV, Pulmonary Vein, Lungs, Pulmonary Artery, LA, LV
B. RA, RV, Pulmonary Artery, Lungs, Pulmonary Vein, LA, LV
The nurse is reviewing Anatomy & Physiology of the heart. Which statement best describes what is meant by atrial kick?
A. The atria contract during systole and attempt to push against closed valves.
B. Contraction of the atria at the beginning of diastole can be felt as a palpitation.
C. Atrial kick is the pressure exerted against the atria as the ventricle contract during asystole.
D. The atria contract towards the end of diastole and push the remaining blood into the ventricles.
D. The atria contract towards the end of diastole and push the remaining blood into the ventricles.
A 67 y/o patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume activity. The patient is most likely experiencing…
A. Claudication
B. Sore Muscles
C. Muscle Cramps
D. Venous insufficiency
A. Claudication
Which statement is true regarding the arterial system?
A. Arteries are large diameter vessels.
B. The arterial system is a high pressure system.
C. The walls of arteries are thinner than those of veins.
D. Arteries can greatly expand to accommodate a large blood volume increase.
B. The arterial system is a high pressure system.
When using a doppler ultrasonic stethoscope the nurse recognizes venous flow when which sound is heard?
A. Low humming sound.
B. A regular “lub dub” pattern.
C. A swishing, whooshing sound.
D. A steady, even flowing sound.
C. A swishing, whooshing sound.
The nurse palpates a weak pedal pulse in the client’s right foot. Which assessment findings should the nurse document that are consistent with diminished peripheral arterial circulation? (SATA)
A. diminished hair on legs.
B. Bruising on extremities.
C. Skin cool to touch.
D. Capillary refill < 3s.
E. Darkened skin on extremities.
A. diminished hair on legs.
C. Skin cool to touch.
During an examination of the anterior thorax, the nurse is aware the trachea bifurcates anteriorly at the?
A. Costal angle
B. Sternal angle
C. Xiphoid process
D. Suprasternal notch
B. Sternal angle
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?
A. Between the scapula.
B. 3rd intercostal space, midclavicular line.
C. 5th intercostal space, midaxillary line.
D. Over the lower lobes on the posterior side.
A. Between the scapula.
During percussion, the nurse knows that a dull percussion elicited over a lung lobe most likely results from?
A. Shallow breathing.
B. Normal lung tissue.
C. Decreased adipose tissue.
D. Increased density of lung tissue.
D. Increased density of lung tissue.
When auscultating the lungs of an adult pt the nurse notes that over the posterior lower lobes low pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:
A. Normally auscultated over the trachea.
B. Bronchial breath sounds and normal in that location.
C. Vesicular breath sounds and normal in that location.
D. Bronchovesicular breath sounds and normal in that location.
C. Vesicular breath sounds and normal in that location.
A patient has been admitted to the ED for a suspected drug overdose. His respirations are shallow, with an irregular pattern and a rate of 12 breaths/min. The nurse interprets the respiration pattern as which of the following?
A. Bradypnea.
B. Cheyne-Stokes respirations.
C. Hypoventilation.
D. Kussmaul Breathing.
C. Hypoventilation.
During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with…
A. Splenomegaly
B. Distended bladder
C. Ascites
D. Constipation
C. Ascites
During an abdominal assessment the nurse would consider which of the following normal findings? (SATA)
A. Presence of a bruit in the femoral area.
B. Tympanic percussion in the umbilical region.
C. Palpable spleen between the 9th and 11th ribs in the left midaxillary line.
D. Dull percussion in the left upper quadrant at the midclavicular line.
E. Dull percussion in the lower left quadrant.
B. Tympanic percussion in the umbilical region.
E. Dull percussion in the lower left quadrant.
The nurse is percussing the right 7th ICS at the midclavicular line. Which sound should the nurse expect to hear?
A. Tympany
B. Dullness
C. Resonance
D. Hyperresonance
B. Dullness
_________ is the volume of blood coming back into the heart
Preload
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour abdomen depicts a ___ profile.
A. Flat
B. Convex
C. Concave
D. Distended
C. Concave
Someone who is very sweaty and lost a lot of blood, will have a _____ preload
low
Someone with a high BP will usually have a ______ afterload
high
A whooshing sound in the heart is a murmur, but a whooshing sound in a vessel it is called a:
bruit
If you have congestive heart failure, you may prefer to sleep with the head of your bed __________________________________________
That position can help shift the fluid that accumulates in the lungs with heart failure downward
elevated or use multiple pillows to prop yourself up;
S1 is louder at the _____
apex
S2 is louder at the _____
base
Conduction of the heart :
starts at the SA node (pacemaker) > AV node > Bundle of His > Bundle branches
Review blood flow of the heart
The structure that is responsible for returning oxygenated blood to the heart is the
a. Pulmonary artery.
b. Pulmonary vein.
c. Superior vena cava.
d. Inferior vena cava.
b. Pulmonary vein.
Chemical receptors that stimulate inspiration are located in the
a. Brain.
b. Lungs.
c. Aorta.
d. Heart.
c. Aorta.
The nurse knows that the primary function of the alveoli is to
a. Carry out gas exchange.
b. Store oxygen.
c. Regulate tidal volume.
d. Produce hemoglobin.
a. Carry out gas exchange.
The nurse knows that anemia will result in
a. Hypoxemia.
b. Impaired ventilation.
c. Hypovolemia.
d. Decreased lung compliance.
Hypoxemia
The process of exchanging gases through the alveolar capillary membrane is known as
a. Disassociation.
b. Diffusion.
c. Perfusion.
d. Ventilation.
b. Diffusion.
A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find
a. Decreased tidal volumes.
b. Increased perfusion.
c. Increased use of accessory muscles.
d. Decreased hemoglobin.
a. Decreased tidal volumes.
While performing an assessment, the nurse hears crackles in the patients lung fields. The nurse also learns that the patient is sleeping on three pillows. What do these symptoms most likely indicate?
a. Left-sided heart failure
b. Right-sided heart failure
c. Atrial fibrillation
d. Myocardial ischemia
a. Left-sided heart failure
Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, crackles, and discomfort when lying supine. Right-sided heart failure is systemic and results in peripheral edema and hepatojugular distention. Atrial fibrillation results in an irregular heart rate. Myocardial ischemia most often results in chest pain, along with shortness of breath, nausea, and fatigue.
The nurse knows that a myocardial infarction is an occlusion of what blood vessel?
a. Pulmonary artery
b. Ascending aorta
c. Coronary artery
d. Carotid artery
c. Coronary artery
Myocardial blood flow is unidirectional; the nurse knows that the correct pathway is which of the following?
a. Right atrium, right ventricle, left ventricle, left atrium
b. Right atrium, left atrium, right ventricle, left ventricle
c. Right atrium, right ventricle, left atrium, left ventricle
d. Right atrium, left atrium, left ventricle, right ventricle
c. Right atrium, right ventricle, left atrium, left ventricle
Unoxygenated blood flows through the vena cava into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium
The nurse caring for a patient with ischemia to the left coronary artery would expect to find
a. Increased ventricular diastole.
b. Increased stroke volume.
c. Decreased preload.
d. Decreased afterload.
d. Decreased afterload.
Normal cardiac output is 4 to 6 L/min in a healthy adult at rest. Which of the following is the correct formula to calculate cardiac output?
a. Stroke volume * Heart rate
b. Stroke volume/Body surface area
c. Body surface area * Cardiac index
d. Heart rate/Stroke volume
a. Stroke volume * Heart rate
A patient’s heart rate increased from 80 bpm to 160 bpm. The nurse knows that what will follow is a(n)
a. Increase in diastolic filling time.
b. Decrease in cardiac output.
c. Increase in stroke volume.
d. Increase in contractility.
ANS: B. Decrease in cardiac output.
An increased heart rate would decrease the diastolic filling time and stroke volume, thus decreasing overall cardiac output. A decrease in cardiac output results from decreased stroke volume and/or decreased heart rate. An increase in stroke volume and contractility would cause a decrease in heart rate to maintain cardiac output.
A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?
Aortic and pulmonic
[semilunar]
__________ - collapse of the alveoli, preventing full intake of oxygen
atelectasis
Your patient arrives to the Emergency Room from home and you notice pitting edema in the patients lower extremities. While you are taking the baseline vitals you may detect her vital signs to be:
drop in BP
Increase in HR
The P wave is represented by which portion of the conduction system?
a. SA node
b. AV node
c. Bundle of HIS
d. Purkinje network
a. SA node
Which statement by the patient indicates an understanding of atelectasis?
a. It is important to do breathing exercises every hour to prevent atelectasis.
b. If I develop atelectasis, I will need a chest tube to drain excess fluid.
c. Atelectasis affects only those with chronic conditions such as emphysema.
d. Hyperventilation will open up my alveoli, preventing atelectasis.
a. It is important to do breathing exercises every hour to prevent atelectasis.
The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the
a. Nailbeds.
b. Oral mucosa.
c. Earlobe.
d. Lower extremities.
b. Oral mucosa.
Because of skin pigmentation, translucent areas of high blood flow such as mucous membranes are best to check for cyanosis, which is a sign of hypoxia. It is important to remember that cyanosis is a late sign of hypoxia.
What assessment finding is the earliest sign of hypoxia?
a. Restlessness
b. Decreased blood pressure
c. Cardiac dysrhythmias
d. Cyanosis
a. Restlessness
A nurse is caring for a patient whose temperature is 100.2 F. The nurse expects this patient to hyperventilate owing to
a. Increased metabolic demands.
b. Anxiety over illness.
c. Decreased drive to breathe.
d. Infection destroying lung tissues.
a. Increased metabolic demands.
A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery. Upon assessment, the nurse expects to find
a. Blood in the sputum.
b. Distended jugular vein.
c. Peripheral edema.
d. Crackles in the lungs.
d. Crackles in the lungs.
Upon auscultation, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is
a. The beginning of the systolic phase.
b. The opening of the aortic valve.
c. S3, the third heart sound.
d. Regurgitation of the mitral valve.
ANS: D
A whooshing sound at the fifth intercostal space is a murmur; a prolapsed valve allows regurgitation that is heard as a whooshing sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. The third heart sound, S3, is heard with heart failure.
A nurse caring for a patient with COPD knows that which oxygen delivery device is most appropriate?
a. Nasal cannula
b. Simple face mask
c. Partial non-rebreather mask
d. Non-rebreather mask
a. Nasal cannula
Nasal cannulas deliver oxygen from 1 to 6 L/min. A patient with COPD should never receive more than 3 L/min because this decreases the drive to breathe, resulting in hypoventilation. All other devices are intended for flow rates greater than 6 L/min.
The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change?
a. Decreased lung defense mechanisms may cause ineffective airway clearance.
b. Thickening of the heart muscle wall decreases cardiac output.
c. Decreased lung capacity makes proper anesthesia induction more difficult.
d. Alterations in mental status prevent patient’s awareness of ineffective breathing.
ANS: A
The age-related change that would affect airway clearance is decreased defense mechanisms, whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient’s oxygen status carefully to make sure the patient does not retain too much of the drug. Heart muscle thickening and mental status do not affect oxygenation in patients undergoing anesthesia. Lung capacity is not related to anesthesia induction.
