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ATI FUNDATION BOOK > ^Ch. 29 Thorax Heart Abdomen > Flashcards

^Ch. 29 Thorax Heart Abdomen Flashcards

1
Q

Midsternal line

A

is through the center of the sternum

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2
Q

midclavicular line

A

is through the midpoint of the clavicle

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3
Q

anterior axillary line

A

is through the anterior axillary folds

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4
Q

midaxillary line

A

is through the apex of axillae

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5
Q

posterior axillary line

A

is through the posterior axillary fold

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6
Q

the right and left scapular lines

A

are through the inferior angle of scapula

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7
Q

vertebral line

A

is along the center of the spine

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8
Q

Dysrhythmia

A

occurs when the heart fails to beat at a regular successive interval

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9
Q

Gallops

A

are extra heart sounds.

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10
Q

ventricular gallops

A

occurs after S2 sounds like Ken-tuck-y

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11
Q

Arterial gallop

A

occurs before S1 sounds Ten-es-see

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12
Q

Murmurs

A

are audible when blood volume in heart increased or its flow is impeded or altered

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13
Q

systolic murmurs

A

occur just after S1

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14
Q

Diastolic murmur

A

occur just after S2

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15
Q

percussion

A

compare sounds from side to side

-percussion of the thorax elicits resonance

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16
Q

unexpected finding percussion

A

dullness- fluid or solid tissues, this can indicate pneumonia or a tumor
-hyper-resonance: in the presence of air, this can indicate pneumothorax or emphysema

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17
Q

Auscultation Bronchial sounds

A

loud, high pitched, hollow quality, expiration longer than inspiration over the trachea

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18
Q

Auscultation Broncho vesicular

A

medium pitch, blowing sounds and intensity with equal inspiration and expiration times over the larger airways

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19
Q

Auscultation vesicular

A

soft, low pitched breezy sounds inspiration three times longer than expiration over most of the peripheral areas of the lungs

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20
Q

Crackles or rales

A

fine to coarse bubbly sounds (not clear with coughing) as air passes through fluid or re-expands collapsed small airways

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21
Q

wheezes

A

high pitched whistling, musical sounds as air passes through narrowed or obstructed airways usually louder on expiration

22
Q

rhonchi

A

coarse loud low pitched rumbling sounds during either inspiration or expiration resulting from fluids or mucus can clear with coughing

23
Q

pleural friction rub

A

dry, grating or rubbing sounds as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration

24
Q

Absence of breath sounds

A

from collapsed or surgically removed lobes

25
Q

S1 sound

A

closure of mitral and tricuspid valve signals signals the beginning of ventricular systole (contraction)

26
Q

S2 sounds

A

closure of the aortic and pulmonic valves signals the beginning of ventricular diastole (relaxation)

27
Q

S3 sounds

A

ventricular gallop

indicates rapid ventricular filling and can be an expected finding in children and young adult

28
Q

S4 reflects

A

a strong atrial contraction and can be an expected finding in older and athletic adult and children

29
Q

Thrills

A

are palpable vibration that can accompany murmurs or cardia malformation

30
Q

Bruits

A

are blowing or swishing sounds that indicate obstructed peripheral blood flow

31
Q

Auscultatory sites of the heart

A 
Aortic 
pulmonic 
Erb's point
tricuspid 
apical/mitral
32
Q

Peripheral vascular system

A

inspect jugular system

33
Q

Jugular venous pressure (JVP)

A

measure at less than 2.5 cm (1in) above the sternal angle

34
Q

Apical pulse or Point of maximal impulse

A

Can be visible just medial to the left midclavicular line at the forth or fifth ICS

35
Q

Halves (lifts)

A

are unexpected, visible elevations of the chest wall that indicate heart failure and are often along the left sternal border or at PMI

36
Q

Thrills

A

use the palm of the hand to feel for vibration similar to that of purring kitten (unexpected finding)

37
Q

bruits

A

are blowing or swishing sounds that indicate obstructed peripheral blood flow

38
Q

Auscultatory sites for the heart

A 
Aortic 
pulmonic
Erb's point 
Tricuspid
Apical/mitral
39
Q

Peripheral vascular system assess for bruits

A
  • Carotid arteries
  • abdominal aorta
  • renal arties: above umbilicus
  • iliac arteries: below the umbilicus
  • femoral arteries: femoral pulses
40
Q

assess skin for

A
  • lesions: bruising, rashes
  • scars: location length
  • silver striae or stretch marks
  • dilated veins
  • Jaundice, cyanosis ascites
41
Q

assess skin for shape or contour

A
  • flat
  • convex: rounded
  • concave: a sunken appearance
  • distended: a large protusion of the abdomen due to fat, fluid flatus.
42
Q

Distended fluid

A

flanks also protrude and when the client turns onto one side the protrusion is mainly midline and there us no change in the flanks

43
Q

distended hernias

A

protrusion through the abdominal muscle wall are visible, especially when the client flexes the abdominal muscles

44
Q

distended flatus

A

the protrusion is mainly midline and there is no change in the flanks

45
Q

Peristalsis

A

wavelike movement visible in thin adults or in pts who have intestinal obstruction

46
Q

pulsations

A

regular beats of movement midline above the umbilicus are expected finding in thin adults. BUT pulsating mass is unexpected

47
Q

expected bowl sounds in tummy

A

5-35/min

48
Q

Seven key chest landmarks

A
  1. Midsternal line
  2. midclavicular line
  3. anterior axillary
  4. midaxillary line
  5. posterior axillary line
  6. R L scapular lines
  7. Vertebral lines
49
Q

a nurse is performing a breast examination for an older adult who is post menopausal. which of the following finding should the nurse expect?

A

Smaller nipples
more pendulous
nipple inversion

50
Q

A nurse is auscultating and percuss a thorax. which finding should the nurse expect

A
  • Resonance

- Broncho vesicular sounds

51
Q

Nurse listens on the left midclavicular line at the 5th ICS. which data is the nurse attempting to auscultate

A
  • closure to mitral valve

- apical heart rate

52
Q

nurse auscultate and percuss a clients abdomen. what finding should the nurse expect

A

Tympany

high pitched clicks

ATI FUNDATION BOOK (11 decks)

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