305 test 4

Question 1

What are the signs and symptoms of DVT?

Answer 1

• Intense sharp, deep muscle pain (may increase with sharp dorsiflexion of the foot) occurs while standing or walking.
• Increased warmth
• Swelling in both legs
• Redness
• Cyanosis is mild but may be absent
• Tender to palpitation
• Homan sign is present only in a few cases

Question 2

Trendelenburg

Answer 2

the patient is on the back on a table or bed whose upper section is inclined 45 degrees so that the head is lower than the rest of the body; the adjustable lower section of the table or bed is bent so that the patient’s legs and knees are flexed. There is support to keep the patient from slipping (used for people with hypotension and for people in shock).

Question 3

Prone position

Answer 3

is a body position in which one lies flat with the chest down and back up. (used to improve oxygenation, to increase lung volume, and to facilitate drainage of secretions).

Question 4

Supine position

Answer 4

the supine position with the person lying on the back, head, and shoulders. (used for hip and knee assessments and McMurray Test).

Question 5

Dorsal recumbent position

Answer 5

position of patient on the back, with lower limbs flexed and rotated outward. (used in vaginal examination, application of obstetrical forceps, and other procedures).

Question 6

Sims position

Answer 6

A position in which the patient lies on one side with the under arm behind the back and the upper thigh flexed, used to facilitate vaginal examination. Also called lateral recumbent position. (used for rectal examinations and enemas).

Question 7

Fowlers position

Answer 7

a position in which a patient, typically in a hospital, is placed when the head of the bed needs to be elevated as high as possible. The upper half of the patient’s body is between 60 degrees and 90 degrees in relation to the lower half of their body. (used to promote oxygenation via maximum chest expansion).

Question 8

What assessment techniques would the nurse use to listen to each of the client’s four valve sounds?

Answer 8

• 2nd right intercostal space: aortic valve area
• 2nd left intercostal space: pulmonic valve
• Left Lower sternal border: tricuspid valve
• 5th intercostal space around left midclavicular line: mitral valve area

1) note rate and rhythm,
2) identify S1 and S2
3) assessment S1 and S2 separately
4) listen for extra heart sounds and
5) listen for murmurs

• Frequency (pitch): high pitched or low pitched.
• Intensity (loudness): loud or soft.
• Duration: very short for heart sounds; silent periods are longer.
• Timing: systole or diastole.

Question 9

What is the meaning of the word “crepitus”? When would you hear this sound?

Answer 9

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.

CREPATATION: is an audible and palpable crunching or grating that accompanies movement. It occurs when articular surfaces in the joints are roughened as with RA.

Question 10

Inversion

Answer 10

moving the sole of the foot inward at the ankle

Question 11

Supination

Answer 11

turning the forearm so that the palm is up

Question 12

Protraction

Answer 12

moving jaw out and parallel to the ground

Question 13

Circumduction

Answer 13

moving the arm in a circle around the shoulder

Question 14

What are the differences between arterial and venous insufficiency?

Answer 14

• Arterial insufficiency- is any condition that slows or stops the flow of blood through your arteries. Arteries are blood vessels that carry blood from the heart to the body.
• Venous insufficiency- is a condition in which the veins have problems sending blood from the legs back to the heart.

Question 15

What are the interventions of arterial and venous insufficiency?

Answer 15

INTERVENTION
-Arterial insufficiency: treatment with blood thinner/ anticoagulant. Prophylaxis and surgery.

-Venous insufficiency: walking and activity or the calf pump, elevation, to promote blood movement and prevent pooling; prophylaxis treatment as a prevention; obesity risk factor (intervention= exercise).

Question 16

What peripheral vascular issues might occur in pregnancy? Why do they occur?

Answer 16

-Hormonal changes cause vasodilation and the resulting drop in blood pressure which drops to its lowest point in the second trimester (can also lead to dizziness and fainting). The growing uterus obstructs drainage of the iliac veins and the inferior vena cava. This causes low blood flow and increases venous pressure causing dependent edema, varicosities in the legs and vulva and hemorrhoids. (Be alert in assessment for edema+HTN=pre-eclampsia)

Question 17

What are the functions of the Vertebral column?

Answer 17

33 connecting bones stacked in a column are a structure for posture, balance and an anchor for surrounding muscles.

Question 18

What are the functions of the Acromion Process?

Answer 18

The bump on the scapula that allows for attachment of the upper limb and chest muscles

to connect that scapula to the clavicle and for the shoulder girdle.

Question 19

What are the functions of the Vertebral foramen?

Answer 19

channel in the middle of vertebrae to house and protect the spinal cord.

Question 20

What are the functions of the Intervertebral disks?

Answer 20

elastic fibrocartilaginous plates that cushion the spine during motion and acts as a shock absorber.

Question 21

What technique is best used when auscultating the 3rd or 4th heart sounds?

Answer 21

• Focus on systole, then DIASTOLE, and listen for any extra heart sounds. Listen with the diaphragm, then switch to the bell, covering all auscultatory areas.
• Grade its timing, loudness, pitch, pattern, quality, location, radiation, and postural changes.

*Have Pt roll to the left side to enhance sounds

Question 22

How would a nurse assess for Herniated nucleus pulposus?

Answer 22

the center of the intervertebral disk, and ruptures into the spinal canal which puts pressure on the local spinal nerve root. (NOTE: sciatic pain/ numbness/and paresthesia of involves dermatome/ decreased mobility/back tenderness/ STRAIGHT LEG raised test reproduces the sciatic pain).

Question 23

How would a nurse assess for Cervical disk herniation?

Answer 23

Buldge of the Cervical spine; (NOTE: pain/ swelling/ ROM/ assess by having the client try to touch chin to chest/ lift chin to the ceiling/ touch ear to each corresponding shouder/ turn chin chin to each shoulder).

Question 24

How would a nurse assess for Osteoarthritis?

Answer 24

Noninflammatory arthritis—Crepitus noted with palpation of the joint. With hand involvement there will often be nontender nodes (Heberden’s, Bouchard’s) on interphalangeal joints. In the knee area, fluid is easily moved around the joint space behind and below the patella. Limited ROM in the affected joint.

Question 25

How would a nurse assess for Bursitis?

Answer 25

Inflammation of bursa. Assess for redness/ swelling, limited ROM, and pain in affected joint.

Question 26

What is edema (generalized) and the cause?

Answer 26

Is bilateral when the cause is generalized (heart failure) or unilateral when it is the result of a local obstruction or inflammation

Question 27

What is lymphedema and the cause?

Answer 27

High-protein swelling of the limb. Most commonly due to breast cancer treatment. Surgical removal or lymph nodes or damage to lymph nodes and vessels with radiation therapy impedes drainage of lymph. Protein-rich lymph builds up in the interstitial spaces, which further raises local colloid oncotic pressure and promotes more fluid leakage. Stagnant lymphatic fluid increases risk for infection, delayed wound healing, chronic inflammation, and fibrosis of surrounding tissue.

Question 28

What is pitting edema and the cause?

Answer 28

Upon palpation your finger should leave no indentation, although a pit commonly is seen if the person has been standing all day or during pregnancy Unilateral/ bilateral (dependent) Pitting edema - Upon palpation your finger should leave no indentation, although a pit commonly is seen if the person has been standing all day or during pregnancy. - occurs with occlusion of a deep vein, or with a lymphatic obstruction. - occurs with heart failure, diabetic neuropathy, and hepatic cirrhosis.

Question 29

What is pulmonary edema and the cause?

Answer 29

- Pulmonary edema is an abnormal buildup of fluid in the air sacs of the lungs, which leads to shortness of breath - It is often caused by congestive heart failure. - When the heart is not able to pump blood to the body efficiently, it can back up into the veins that take blood through the lungs to the left side of the heart.

Question 30

What does a bruit sound like?

Answer 30

- this is a blowing, swishing sound indicating blood flow turbulence. - is the unusual sound that blood makes when it rushes past an obstruction (called turbulent flow) in an artery. - FOUND IN CAROTID

Question 31

What do murmurs sound like?

Answer 31

gentle, blowing or swooshing sounds due to turbulent blood flow. -FOUND IN HEART

Question 32

What does S4 sound like?

Answer 32

- A venticular filling sound. The sound due to the vibration of noncompliant ventricles when the atria contract and push blood into them. - Very soft low pitch. - a galloping sound.

Question 33

What does stridor sound like?

Answer 33

- is a high pitched inspiratory crowing sound heard without the stethoscope, - louder in neck than over chest wall, occurring with upper airway obstruction, swelling or inflamed tissues (e.g. croup, foreign body aspiration, or acute epiglottitis).

Question 34

What do crackles sound like?

Answer 34

are loud, low pitched, bubbling and gurgling, and cracking sounds - start in early inspiration and may be present in expiration, -may decrease somewhat by suctioning or coughing but will reappear shortly - sounds like opening a Velcro fastener (e.g. pulmonary edema, pneumonia).

Question 35

What does friction rub sound like?

Answer 35

- a very superficial sounds that is CORSE and LOW pitched, - it has a grating quality as if two pieces of leather are being rubbed together, - sounds just like crackles, but close to the ear, sounds louder if you push the stethoscope harder onto the chest wall, sound is inspiratory and expiratory (e.g. pleuritis).

Question 36

What does wheezing sound like?

Answer 36

HIGH PITCH: a musical squeaking sounds that sound like multiple notes, predominate in expiration but may occur in both (e.g. acute asthma, chronic emphysema). LOW PITCH:sounds like a single note, musical snoring, moaning sounds, they are heard throughout the cycle, although they are more prominent on expiration, may clear somewhat by coughing (e.g. bronchitis, single bronchus obstruction from airway tumor).

Question 37

What are the musculoskeletal signs and symptoms of downs syndrome?

Answer 37

- simian crease, short broad fingers, incurving of little fingers and low thumbs. - Distinctive facial features, such as a flat face, small ears, slanting eyes, and a small mouth, short neck and short arms and legs, weak muscles and loose joints.

Question 38

What are the signs and symptoms of spina bifida?

Answer 38

incomplete closure of posterior part of vertebrae results in a neural tube defect. - Seriousness varies from skin defect along the spine to protrusion of the sac containing meninges, spinal fluid or malformed spinal cord. - Most serious is myelomeningocele-meninges and neural tissue protrude. Child is usually paralyzed below the lesion - skin sensitivity

Question 39

What are the signs and symptoms of hip dislocation?

Answer 39

head of the femur is displaced out of the cup-shaped acetabulum. Occurs in 1:500 to 1:1000 births, common 7:1 in girls. - Signs include limited abduction of flexed thigh, Ortolani and Barlow signs, - asymmetric skin creases or gluteal folds, limb length discrepancy, - positive indication of Trendelenburg sign in older adults.

Question 40

What is the best assessment approach to use when performing a musculoskeletal assessment on a client?

Answer 40

* Make the person comfortable before and throughout * Drape for full visualization of area you are assessing without needless exposure * Head to toe, proximal to distal (from the midline outward) * Support each joint at rest, ROM/MUSCLE TESTING * Take care when examining inflamed areas - use firm support, gentle movement, and gentle return

Question 41

How might the maternal hormones affect the newborn's physical appearance?

Answer 41

In newborn males and females, the breasts may look enlarged/ and may have a white discharge, --dissipates by the second or third day from maternal estrogen.

Question 42

What is the best approach for listening to the chest of a large breasted person?

Answer 42

- Do not place your stethoscope directly over the female breast. - Displace the breast and listen directly over the chest wall.

Question 43

What does bronchovesicular normal breath sound like and where are they heard?

Answer 43

- is the normal breath sound heard over major bronchi, - characterized by moderate pitch,amplitude, - inspiration equal to expiration - Heard over major bronchi where fewer alveoli are located, posterior, between scapulae especially on right, anterior, around upper sternum in first and second intercostal spaces.

Question 44

What does vesicular normal breath sound like and where are they heard?

Answer 44

- the soft, low-pitched, normal breath sounds heard over peripheral lung fields. - IN/EX - Heard over peripheral lung fields where air flows through smaller bronchioles and alveoli.

Question 45

What does bronchial sounds normal breath sound like and where are they heard?

Answer 45

- high pitch, loud amplitude, quality is harsh/hollow/tubular - located over the trachea and larynx.

Question 46

How would you assess kyphosis, scoliosis, lordosis, pectus excavatum/carinatum? (Know what each term is)

Answer 46

- Perform the inspection, palpation, percussion and auscultation on the posterior and lateral thorax then move to the face the patient and repeat maneuvers on the anterior chest. b. Kyphosis—(exaggerated posterior curvature—humpback--associated with aging, postmenopausal women; c. Scoliosis—lateral S shaped curve to thoracic and lumbar spinal areas; note unequal hip levels, rib interspaces flared on convex side, more prevalent in girls and adolescents; d. Lordosis—pronounced lumbar curve common in obese people; pregnant women e. Pectus Excavatum—sunken sternum and adjacent cartilages, congenital and not symptomatic; f. Pectus Carinatum—forward protrusion of sternum, minor deformity and no treatment unless severd.

Question 47

What is the Ballottement assessment of the knee?

Answer 47

This test for the patella, is reliable when larger amounts of fluid are present. It is performed by - -using left hand to compress the suprapatellar pouch to move any fluid into the knee joint. - -With the right hand, push the patella sharply against the femur. You should hear a CLICK - -If no fluid is present, the patella is already snug against the femur.

Question 48

What is the Tinel sign?

Answer 48

This test is used to identify carpal tunnel syndrome. - -In carpal tunnel syndrome, percussion of the median nerve produces burning and tingling along its distribution, which is a positive Tinel sign. - -Direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand (Negative Tinel sign).

Question 49

What is Phalen's test?

Answer 49

Tests for carpal tunnel syndrome. - Ask the person to hold both hands back to back while flexing the wrists 90 degrees. - -Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. In the carpal tunnel hand, this test produces numbness and burning..

Question 50

What is McMurray's test?

Answer 50

Special test for meniscal tears. - -Perform this test when the person has reported a history of trauma followed by locking, giving way, or local pain in the knee. 1) Position the person the person supine as you stand on the affected side. 2) Hold the heel, and flex the knee and hip. 3) Place your other hand on the knee with fingers in the medial side. 4) Rotate the leg in and out to loosen the joint. Externally rotate the leg, and push inward stress on the knee. 5) you should HEAR a CLICK if positive.

Question 51

What conditions cause clubbing of nails?

Answer 51

- -Congenital cyanotic heart disease | - -neoplastic and pulmonary diseases.

Question 52

What does TB sound like?

Answer 52

Auscultation-Normal or DECREASED VESICULAR breath sounds. Adventitious Sounds-CRACKLES over upper lobes common, persist following full expiration and cough.

Question 53

What does pneumonia sound like?

Answer 53

Auscultation-LOUDER with patent BRONCHUS, as if coming directly from larynx. Voice sounds have increased clarity; bronchophony, egophony, whispered pectoriloquy present. Children—diminished breath sounds may occur early in pneumonia. Adventitious Sounds- CRACKLES, FINE to MEDIUM.

Question 54

What does atelectasis sound like?

Answer 54

Auscultation-Breath sounds DECREASED VESICULER or absent over area. -Voice sounds variable, usually decreased or absent over affected area. Adventitious Sounds- NONE if bronchus is obstructed. Occasional fine crackles if bronchus is patent.

Question 55

What does asthma sound like?

Answer 55

Auscultation-Diminished air movement. Breath sounds decreased, with prolonged expiration. Adventitious Sounds-Bilateral wheezing on expiration, sometimes inspiratory and expiratory WHEEZING.

Question 56

What are the common changes seen in the elderly client's musculoskeletal system?

Answer 56

Kyphosis is common in the elderly client, along with increased anteroposterior diameter, giving a round barrel shape. Compensates by holding head extended and tilted back. Decreased subcutaneous fat. Chest expansion may be somewhat decreased, although should still be symmetric. The costal cartilages become calcified with aging, resulting in a less mobile thorax.

Question 57

What is the meaning behind the following numbers for muscle strength? 1+, 2+, 3+, 4+, and 5+ bilaterally.

Answer 57

1+ Slight contraction 2+ Full ROM with gravity eliminated (passive motion) 3+ Full ROM with gravity 4+ Full ROM against gravity, some resistance. 5+ Full ROM against gravity, full resistance

Question 58

What are the risk factors for osteoporosis and who is at greatest risk?

Answer 58

- Lack of estrogen - Age, gender, ethnicity, bone structure/body weight, family hx, smoking, ETOH, medications, prior hx of broken bones - Greater risk=older/aging adults

Question 59

What is the meaning behind the following numbers for pulse strength scale? 0, 1+, 2+, 3+.

Answer 59

0=absent 1+=weak, thread- hard to palpate, need to search for it, may fade in/out, easily obliterated by pressure 2+=normal 3+=increased, full, bounding-easily palpable, pounds under your fingertips

Question 60

What medical conditions could cause an unequal chest expansion upon assessment?

Answer 60

- atelectasis, - lobar pneumonia, - pleural effusion - Thoracic trauma (fractured ribs, pnemothorax)

Question 61

What is paroxysmal nocturnal dyspnea and what medical conditions can cause it?

Answer 61

- Awakening from sleep with SOB and needing to be upright to achieve comfort. - HF (WITH ONE OR MORE SIDES) - Can cause diaphoresis and hypoxia

Question 62

Where are the following nodes located? The cervical node, the axillary node, the epitrochlear node, and the inguinal node.

Answer 62

- Clavicle node: drain head and neck (STERNOMASTOID/TRAP) - Axillary nodes: drain breast and upper arm - Epitochlear node: antecubital fossa, drain the hand and lower arm - Inguinal node: groin, drain lower extremity, external genitalia, anteriror abdominal wall

Question 63

Cheyne-Stokes respiration

Answer 63

respirations gradually WAX AND WANE in a regular pattern, iINCREASING in rate and depth and then decreasing. Breathing periods last 30-45 seconds with periods of apnea alternating the cycle. - SEVERE HF - NORMALLY IN INFANT AND ELDERLY DURING SLEEP

Question 64

Chronic obstructive breathing

Answer 64

obstructive breathing: normal inspiration and PROLONGED expiration to OVERCOME increased airway resistance.

Question 65

Kussmaul breathing

Answer 65

A type of HYPERVENTALATION that occurs with diabetic ketoacidosis. TRYING TO VENT OFF

Question 66

What are the movements of the following? Flexion, Abduction, Adduction, Hyperextension.

Answer 66

- Flexion: bending a lib at the joint - Abduction: moving a limb away from the midline of the body - Adduction: moving a limb toward the midline of the body - Hyperextension: straightening of a limb at the joint beyond its normal range of motion.

Question 67

What is tactile fremitus and what is the technique used to assess for it?

Answer 67

Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchymea to the chest wall, where you feel the vibration. Use either a palmar base of the fingers or ulnar edge of one hand and touch the person's chest while he/she repeats the words "ninety-nine." Start over the lung apices and palpate from one side to another.

Question 68

What does decreased fremitus sound like?

Answer 68

Occurs when anything obstructs the transmission of vibrations. Any barrier that comes between the sound and your hand will decrease fremitus.

Question 69

What does increased fremitus sound like?

Answer 69

Occurs with compression or consolidation of lung tissue (e.g. lobar pneumonia). * ONLY GROSS CHANGES INCREASE FREMITUS.

Question 70

When would increased/secreased fremitus occur during an assessment?

Answer 70

Decreased: Occurs when anything obstructs transmission of vibration (eg. Obstructed bronchus, pleural effusion or thickening pneumothorax, or emphysema) Increased: Occurs with compression or consolidation of lung tissue (eg. Lobar pneumonia). This is present only when the bronchus is patent and when consolidation extends to the lung surface. Note that only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect fremitus.

Question 71

What does arterial and venous insufficiency look like?

Answer 71

ARTERIAL: Deep rubor, motor/sensory loss, arterial ischemic ulcer. VENOUS: Venous Ulcer: varicose veins (chronic insufficiency), DVT (acute insufficiency)

Question 72

Cardiac edema

Answer 72

Worse in the evening and better in the morning after elevating the legs at night. Is bilateral; unilateral swelling has a local vein cause.

Question 73

a. Flexion

Answer 73

bending a limb at a joint.

Question 74

b. Abduction

Answer 74

moving a limb away from the midline of the body.

Question 75

c. Adduction

Answer 75

moving a limb toward the midline of the body

Question 76

d. Hyperextension

Answer 76

the extension of a part of the body beyond normal limits