a nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continous high-pitched squeaking sounds. The nurse should document this as which breath sounds?
Wheezes
What are rhonchie sounds?
rumbling, snoring, rattling sounds resulting from fluid or mucous
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect the pt to have
Kyphosis
What is kyphosis?
forward “stooping” posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is common in older adults and increases in age.
What is Scoliosis
lateral curvature of the thoracic spine, most often found in adolescents.
What is ankylosis?
immobility and consolidation of a joint, often result of disuse
What does pneumonia sound like?
present with crackles in the lungs due to increased secretions
What is petechiae?
tiny red, flat spots that appear on your skin. They’re caused by bleeding. They sometimes appear in clusters and may look like a rash
a nurse is assessing a client’s cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?
the left second intercostal space - this is the location where the nurse can palpate pulsations at the pulmonic valve area. This is the site for palpating lifts and heaves in the area
What is the conjunctivae?
the mucous membrane that covers the front of the eye and lines the inside of the eyelids.
Which pulse should not be taking bilaterally at the same time?
carotid because this action can induce syncope by reducing blood flow to the brain and cause a reflex drop in the blood pressure and heart rate
What do murmurs sound like?
loud, turbulent sounds the nurse can hear between the usual, expected heart sounds. They create a whoosing or swishing sound.
What is the difference between systolic and diastolic murmurs
systolic murmurs: between S1 and S2
diastolic: between S2 and the next S1
