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Flashcards in Assessment Deck (35)
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1

Vibration produced when patient articulates "99"

Tactile fremitus

2

Vesicular

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

3

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

Bronchovesicular

4

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

Bronchi

5

abnormal lung sounds caused by fluid or inflammation

Adventitious

6

grating sound or vibration heard during inspiration and expiration

pleura friction rub

7

squeaky sounds heard during inspiration and expiration associated with narrowed airways

sibilant wheeze

8

musical sounds or vibrations commonly heard on expiration

sonorous wheeze

9

abnormal sounds caused by turbulence within a heart valve

murmurs

10

Bruit

turbulence within a blood vessel

11

same concentrations as body fluids

Isotonic fluids

12

Hypertonic solution

solute concentration greater than that of body fluids

13

hypotonic solution

solute concentration less than that of body fluids

14

fluid deficit causes

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

15

signs and symptoms of fluid deficit

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

16

increase in the interstitial compartment, intravascular compartment or both

fluid overload - isotonic gain

17

causes of fluid overload

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

18

signs and symptoms of fluid overload

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

19

cause of hypokalemia (<3.5 mEq/L)

vomiting
gastric suction
prolonged diarrhea
diuretics and steroids
inadequate intake

20

signs and symptoms of hypokalemia

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

21

hyperkalemia causes (> 5.0 mEq/L)

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

22

signs and symptoms of hyperkalemia

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

23

causes of hyponatremia (<135 mEq/L)

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

24

sign and symptoms of hyponatreia

nausea
muscle cramps
confusion
muscular twitching, coma
seizures
headache
delirium

25

causes of hypernatremia (>145)

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

26

signs and symptoms of hypernatremia

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

27

causes of hypocalcemia

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

28

signs and symptoms of hypocalcemia

tetany
hyperactive reflexes
confusion
paresthesias
irritability
seizures

29

causes of hypercalcemia

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

30

signs and symptoms of hypercalcemia

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

31

causes of hypomagnesemia

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

32

signs and symptoms of hypomagnesemia

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

33

causes of hypermagnesemia

renal failure
excessive magnesium administration (antacids, cathartics)

34

signs and symptoms of hypermagnesemia

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

35

infiltrated IV site

apply warm compresses