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Fall 2015 Nursing School > 319 Exam 2 > Flashcards

319 Exam 2 Flashcards

(65 cards)

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1
Q

Cardiac subjective data

A 
CP
SOB
Cough
Any Hx of HTN, MI, CAD
PND
Exercise intolerance 
Palpitations 
Claudication
Edema
Syncopy
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2
Q

Respiratory subjective data

A 
Cough
SOB
Orthopnea 
Chest pain
Past history of respiratory infection
Trauma
Surgery
PMH
Environmental exposures
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3
Q

Subjective in common to both respiratory and cardiovascular

A

SOB
CP
Cough
Exercise intolerance

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4
Q

Respiratory Inspection

A

Symmetry?
Cyanosis?
Lesions?

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5
Q

Respiratory palpation

A

Thoracic expansion

Tactile fremitus (symmetrical vibration)

Tenderness

Lumps

Temperature

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6
Q

Palpation for tenderness, lumps, temperature using…

A

Fingers

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7
Q

Respiratory percussion

A

Resonance

Diaphragmatic excursion

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8
Q

High pitched, loud

A

Bronchial

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9
Q

Moderate, moderate

A

Bronchovesicular

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10
Q

Low pitch, soft

A

Vesicular

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11
Q

Broncophony

A

Say 99, hear barely

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12
Q

Egophony

A

Say eeee, expect eeee

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13
Q

Whispered pectoriloquy

A

Whispers, should be barely audible

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14
Q

S1 is from…

A

AV valves closing

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15
Q

S1 is loudest near the

A

Apex

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16
Q

S2 is from…

A

Closing of semilunar valves

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17
Q

S2 is loudest at the…

A

Base

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18
Q

Respiratory nursing diagnosis

A

Restlessness r/t dyspnea

Cyanosis r/t air hunger

Impaired cognitive function r/t ineffective breathing patterns

Ineffective airway clearance r/t inability to cough effectively

Impaired gas exchange r/t tachypnea

Activity intolerance r/t accessory muscle use

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19
Q

Cardiac nursing diagnosis

A

Activity intolerance r/t CP

Altered tissue perfusion r/t decreased cardiac output

Sensory alteration-tactile r/t impaired circulation

Impaired healing-foot ulcers r/t impaired circulation

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20
Q

For the respiratory exam auscultate using the…

A

Diaphragm

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21
Q

Crackles are heard during…

A

Inspiration

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22
Q

Friction rubs are heard during…

A

Inspiration and expiration

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23
Q

Not cleared by coughing

A

Crackles

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24
Q

Course sounds cleared with coughing…

A

Rhonchi

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25
High-pitched piercing sound
Stridor
26
This sound is indicative of upper airway obstruction
Stridor
27
Apgar scoring system
HR Respiratory effort Muscle tone Color Reflex irritability to
28
The first BP change seen in shock is a...
Narrowing pulse pressure (Diastolic BP starts to rise)
29
What is a good heart rate?
60 to 100 BPM traditional | 50 to 90 BPM AHA
30
Early signs of shock
``` Tachycardia Tachypnea BP varies/pulse pressure narrows Decreased urinary output Elevated blood glucose ```
31
What three positions is orthostatic hypotension checked?
Lying Sitting Standing
32
What signifies orthostatic hypotension?
Drop in BP more than 20 mm systolic Increase in HR more than 20 BPM
33
Skin turgor is not helpful in…
Middle-aged/older adults
34
Signs of poor perfusion
Skin color Skin temperature Capillary refill Peripheral pulses
35
Different cardiac symptoms in women
Shortness of breath Fatigue Epigastric symptoms Neurologic symptoms
36
Cases where cardiac disease presents without chest pain
Elderly Diabetics Alcoholics and drug abusers Previous mediastinal or thoracic surgery
37
For cardiovascular inspection what is normal?
No pulsation or apical pulsation
38
For cardiovascular palpation what is normal?
Only the apical impulse should be felt
39
S1 is the start of
Systole
40
S2 is the start of
Diastole
41
S3
Ventricular gallop | Indicative of LV failure
42
S4
Associated with HTN and CAD
43
Murmurs are graded on a scale of…
1 to 6
44
Problem with the valve not opening fully
Stenosis
45
Problem with valve not staying closed completely
Regurgitation
46
MS.ARD
Mitral stenosis and aortic regurgitation cause diastolic murmurs
47
MR. PASS
Mitral regurgitation and Pulmonic or aortic stenosis cause systolic murmurs
48
Peripheral vascular inspection
``` Color Clubbing Capillary refill Temperature Edema Ulceration Hair distribution ```
49
Auscultate to the carotids with
Bell
50
5 locations of auscultation for bruits
``` Carotid Abdominal Renal Iliac Femoral ```
51
What angle is JVP measured at?
45 degrees
52
What is a normal JVP measurement?
2 cm or less
53
Peripheral Pulse are measured on a scale of
0-3+
54
A normal peripheral pulse is
2+
55
Weak thready pulse
Peripheral artery disease PAD Decreased CO
56
Regular rhythm, alternating weak strong
Pulsus Alternans Indicative of Heart Failure
57
Pulse weaker inspiration, stronger expiration
Pulsus Paradoxus Indicative of Tamponade
58
Symptoms for PAD
``` Calf/thigh pain Worse with activity Color change Temp change Loss of hair Slow wound healing Diminished pulses ```
59
Palpation for Peripheral Vascular
Warmth Tenderness Edemar
60
Edema scale range
1+ to 4+
61
Causes of pitting edema
``` Venous stasis Heart failure Liver failure Renal failure Poor lymphatic drainage ```
62
Venous stasis causes
Pregnancy Obesity DVT/VTE Long periods sitting/standing
63
Peripheral vascular arterial deficiency
``` Ischemic ulcer Hairlessness Cool to touch Diminished pulses Claudication (leg cramps) Pain relieved by rest Color changes (cyanosis, e palor, d rubor) ```
64
Ankle-brachial pressure index normal range
0.9-1.2
65
DVT symptoms
Acute pain Edema Redness homan's sign (lower leg)

Fall 2015 Nursing School (17 decks)

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