Assessment

Question 1

Vibration produced when patient articulates “99”

Answer 1

Tactile fremitus

Question 2

Vesicular

Answer 2

soft and low-pitched breezy sounds heard over most of peripheral lung fields; inspiration >= expiration

Question 3

medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration=expiration

Answer 3

Bronchovesicular

Question 4

loud, coarse blowing sounds head over the trachea; inspiration <= expiration

Answer 4

Bronchi

Question 5

abnormal lung sounds caused by fluid or inflammation

Answer 5

Adventitious

Question 6

grating sound or vibration heard during inspiration and expiration

Answer 6

pleura friction rub

Question 7

squeaky sounds heard during inspiration and expiration associated with narrowed airways

Answer 7

sibilant wheeze

Question 8

musical sounds or vibrations commonly heard on expiration

Answer 8

sonorous wheeze

Question 9

abnormal sounds caused by turbulence within a heart valve

Answer 9

murmurs

Question 10

Bruit

Answer 10

turbulence within a blood vessel

Question 11

same concentrations as body fluids

Answer 11

Isotonic fluids

Question 12

Hypertonic solution

Answer 12

solute concentration greater than that of body fluids

Question 13

hypotonic solution

Answer 13

solute concentration less than that of body fluids

Question 14

fluid deficit causes

Answer 14

vomiting
diarrhea
GI suction
sweating and warm weather
decreased intake; increased caffeine and alcohol intake
hyperthermia
diuretics

Question 15

signs and symptoms of fluid deficit

Answer 15

weight loss
decreased skin turgor
oliguria
concentrated urine
postural hypotension
weak, rapid pulse
increased hematocrit, hemoglobin, BUN, Na, serum osmolality
Hyperthermia- increased pulse, decreased BP, disorientation
orthostatic hypotension, falls, pressure ulcers, constipation, dry oral mucous

Question 16

increase in the interstitial compartment, intravascular compartment or both

Answer 16

fluid overload - isotonic gain

Question 17

causes of fluid overload

Answer 17

heart failure
renal failure
Cirrhosis of the liver
excessive ingestion of Na
excessive or too rapid intravenous infusion

Question 18

signs and symptoms of fluid overload

Answer 18

edema
distended veins
increased BP
bounding pulse
crackles; increased RR, shallow respiration
decreased hematocrit and BUN (5-20 mg/dL)
weight gain

Question 19

cause of hypokalemia (<3.5 mEq/L)

Answer 19

vomiting
gastric suction
prolonged diarrhea
diuretics and steroids
inadequate intake

Question 20

signs and symptoms of hypokalemia

Answer 20

anorexia, N/V
weak peripheral pulses
muscle weakness, paresthesias; decreased deep tendon reflexes
impaired urine concentration
ventricular dysrhythmias 
potential for digitalis toxicity
shallow respirations

Question 21

hyperkalemia causes (> 5.0 mEq/L)

Answer 21

renal failure 
use of K supplements
burns
crushing injuries
severe infection
K-sparing diuretics
ACE inhibitors

Question 22

signs and symptoms of hyperkalemia

Answer 22

EKG changes-peaked T waves, wide QRS complexes
dysrhythmias, ventricular fibrillation, heart block
cardiac arrest
muscle twitching and weakness
numbness in hands and feet and around mouth
nausea
Diarrhea

Question 23

causes of hyponatremia (<135 mEq/L)

Answer 23

vomiting
diuretics
excessive administration of dextrose and water IVs
burns, wound drainage
excessive water intake
SIADH
kidneys unable to excrete free water

Question 24

sign and symptoms of hyponatreia

Answer 24

nausea
muscle cramps
confusion
muscular twitching, coma
seizures
headache
delirium

Question 25

causes of hypernatremia (>145)

Answer 25

hyperventilation diabetes insipidus hypertonic tube feedings without water supplements ingestion of OTC drugs such as Alka-Seltzer saltwater inadequate water ingestion

Question 26

signs and symptoms of hypernatremia

Answer 26

``` Elevated temperature weakness Disorientation irritability and restlessness thirst dry, swollen tongue sticky mucous membranes postural hypotension with decrease ECF hypertension with normal or increase ECF tachycardia mental status changes, coma ```

Question 27

causes of hypocalcemia

Answer 27

``` hypoparathyroidism pancreatitis renal failure steroids and loop diuretics inadequate intake post thyroid surgery ```

Question 28

signs and symptoms of hypocalcemia

Answer 28

``` tetany hyperactive reflexes confusion paresthesias irritability seizures ```

Question 29

causes of hypercalcemia

Answer 29

``` malignant neoplastic diseases hyperparathyroidism prolonged immobilization excessive intake immobility excessive intake of calcium carbonate antacids ```

Question 30

signs and symptoms of hypercalcemia

Answer 30

lack of coordination anorexia, N/V confusion, decreased level of consciousness personality changes dysrthythmias, heart block, cardiac arrest

Question 31

causes of hypomagnesemia

Answer 31

``` alcoholism GI suction Diarrhea intestinal fistulas poorly controlled diabetes mellitus malabsorption syndrome ```

Question 32

signs and symptoms of hypomagnesemia

Answer 32

``` increased neuromuscular irritability tremors tetany hyperactive deep tendon reflexes seizures dysrhythmias disorientation confusion ```

Question 33

causes of hypermagnesemia

Answer 33

renal failure | excessive magnesium administration (antacids, cathartics)

Question 34

signs and symptoms of hypermagnesemia

Answer 34

``` depresses the CNS depresses cardiac impulse transmission cardiac arrest facial flushing muscle weakness absent deep tendon reflexes paralysis shallow respirations ```

Question 35

infiltrated IV site

Answer 35

apply warm compresses