^Ch. 29 Thorax Heart Abdomen

Question 1

Midsternal line

Answer 1

is through the center of the sternum

Question 2

midclavicular line

Answer 2

is through the midpoint of the clavicle

Question 3

anterior axillary line

Answer 3

is through the anterior axillary folds

Question 4

midaxillary line

Answer 4

is through the apex of axillae

Question 5

posterior axillary line

Answer 5

is through the posterior axillary fold

Question 6

the right and left scapular lines

Answer 6

are through the inferior angle of scapula

Question 7

vertebral line

Answer 7

is along the center of the spine

Question 8

Dysrhythmia

Answer 8

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

Question 9

Gallops

Answer 9

are extra heart sounds.

Question 10

ventricular gallops

Answer 10

occurs after S2 sounds like Ken-tuck-y

Question 11

Arterial gallop

Answer 11

occurs before S1 sounds Ten-es-see

Question 12

Murmurs

Answer 12

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

Question 13

systolic murmurs

Answer 13

occur just after S1

Question 14

Diastolic murmur

Answer 14

occur just after S2

Question 15

percussion

Answer 15

compare sounds from side to side

-percussion of the thorax elicits resonance

Question 16

unexpected finding percussion

Answer 16

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

Question 17

Auscultation Bronchial sounds

Answer 17

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

Question 18

Auscultation Broncho vesicular

Answer 18

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

Question 19

Auscultation vesicular

Answer 19

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

Question 20

Crackles or rales

Answer 20

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

Question 21

wheezes

Answer 21

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

Question 22

rhonchi

Answer 22

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

Question 23

pleural friction rub

Answer 23

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

Question 24

Absence of breath sounds

Answer 24

from collapsed or surgically removed lobes

Question 25

S1 sound

Answer 25

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

Question 26

S2 sounds

Answer 26

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

Question 27

S3 sounds

Answer 27

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

Question 28

S4 reflects

Answer 28

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

Question 29

Thrills

Answer 29

are palpable vibration that can accompany murmurs or cardia malformation

Question 30

Bruits

Answer 30

are blowing or swishing sounds that indicate obstructed peripheral blood flow

Question 31

Auscultatory sites of the heart

Answer 31

``` Aortic pulmonic Erb's point tricuspid apical/mitral ```

Question 32

Peripheral vascular system

Answer 32

inspect jugular system

Question 33

Jugular venous pressure (JVP)

Answer 33

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

Question 34

Apical pulse or Point of maximal impulse

Answer 34

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

Question 35

Halves (lifts)

Answer 35

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

Question 36

Thrills

Answer 36

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

Question 37

bruits

Answer 37

are blowing or swishing sounds that indicate obstructed peripheral blood flow

Question 38

Auscultatory sites for the heart

Answer 38

``` Aortic pulmonic Erb's point Tricuspid Apical/mitral ```

Question 39

Peripheral vascular system assess for bruits

Answer 39

- Carotid arteries - abdominal aorta - renal arties: above umbilicus - iliac arteries: below the umbilicus - femoral arteries: femoral pulses

Question 40

assess skin for

Answer 40

- lesions: bruising, rashes - scars: location length - silver striae or stretch marks - dilated veins - Jaundice, cyanosis ascites

Question 41

assess skin for shape or contour

Answer 41

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

Question 42

Distended fluid

Answer 42

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

Question 43

distended hernias

Answer 43

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

Question 44

distended flatus

Answer 44

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

Question 45

Peristalsis

Answer 45

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

Question 46

pulsations

Answer 46

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

Question 47

expected bowl sounds in tummy

Answer 47

5-35/min

Question 48

Seven key chest landmarks

Answer 48

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

Question 49

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

Answer 49

Smaller nipples more pendulous nipple inversion

Question 50

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

Answer 50

- Resonance | - Broncho vesicular sounds

Question 51

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

Answer 51

- closure to mitral valve | - apical heart rate

Question 52

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

Answer 52

Tympany | high pitched clicks