Exam 2: NR414 Rev 2 Flashcards Preview

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Flashcards in Exam 2: NR414 Rev 2 Deck (138):
1

This is a term for "dry mouth"

Xerostomia

2

Another name for nosebleed

Epistaxis

3

Jarvis:

 

The second heart sound is the result of:

 

closing of the mitral and tricuspid valves

4

Jarvis:

 

When palpating an apical impulse what is the normal size?

 

2 cm

5

Jarvis:

 

Where do you listen in the pulmonic valve area?

 

the 2nd Left Interspace

6

Jarvis:

What is the difference between S2 & S3?

 

S3 is lower pitched and is heard at the apex

7

Jarvis:

 

When auscultating the heart your first step is to:

 

identify S1 & S2

8

Jarvis:

Where is a split S2 heard most clearly?

 

pulmonic

9

The most common site of nosebleeds

Kiesselbach Plexus

10

What is a common cause of dry mouth?

medications

11

Which side of the lungs is narrower and only has 2 sides

Left lung

12

This breath sound is moderate in pitch, inspiration= expiration

Bronchovesicular breath sounds

13

Where is the left lateral lung located?

  • sixth rib, midclavicular line

14

Where is the Right Lateral Lung Border?

Fifth intercostal

15

Where is the posterior apex of the lung border?

C7

16

Bronchial Tracheal Characteristics:

  • High pitched
  • Inspiration < Experiation
  • Harsh,Hollow, Tubular
  • Trachea/Larynx

17

This breath sound is over the major bronchi where fewer alveoli are located: Posterior b/w capulae especially on Rt anterior.  Around Upper sternum in 1st and 2nd ICS

Bronchovesicular

18

This breath sound is over peripheral lung fields where air flows through smaller bronchioles and alveoli

Vesicular

19

Characteristics of Vesicular Sounds

  • Low pitch
  • inspiration > Expiration
  • Rustling like wind in trees

20

This is purposeful and expands the alveoli. May indicate emotional dysfunction and could lead to hyperventilation.

Sigh

21

Name this respiration pattern

Biot's Respiration

22

This is a series of normal respiration followed by a period of apnea.  Cycle is variable, lasting from 10- 60 sec.

  • Biots Respiration (irregular)
  • Seen with head trauma, brain abscess, heat stroke spinal meningitis, & encephalitis

23

Name this respiration pattern?

 

Normal Adult

24

Rate is usually 10-20 breaths/min. Depth 500-800ml. Pattern is even.

Normal Adult

25

Name this respiration pattern?

 

Cheyne Stokes

26

Breathing periods last 30-45 sec, with 20 sec periods of apnea.  Respirations wax and wane.

  • Cheyne Stokes
  • severe heart failure, drug OD, older adult during sleep, infant

27

Name this respiration pattern

Tachypnea

29

Rapid shallow breathing. >24/min.

  • Tachypnea
  • exercise, fever, fear, pneumonia

30

Name this respiration pattern

Bradypnea

31

Slow breathing,

  • Bradypnea
  • drug induced
  • diabetic coma

32

Name this respiration pattern

 

hyperventilation

33

Rate & depth both increase with this respiration type.  Blows off CO2 causing a low level in the blood.

  • Hyperventilation
  • extreme exertion, fear, anxiety, hepatic coma, diabetic, lesions of the brain

34

Name this respiration pattern

 

Chronic Obstructive Breathing

35

This is when you have prolonged expiration to overcome airway resistance.

  • Chronic Obstructive Breathing
  • can cause air trapping (dyspneic episode)

36

Name this respiration pattern

Hypoventilation

37

An irregular shallow pattern of breathing caused by an OD of narcotics, anesthetics or prolonged bed rest.

  • Hypoventilation

38

Name this adventitious sound pattern

Stridor

39

This sound is high pitched, monphonic. It is louder in the neck than over the chest wall.  Upper airway obstruction- swollen tissues or lodged foreign body.

  • Stridor
  • croup, acute epiglottis child, foreign inhalation.

40

Name this adventitious sound pattern

41

Name this adventitious inhalation pattern

Wheeze high pitched (sibilant

42

This is a high pitched musical squeaking/polyphonic.  Predominantly in expiration. Sounds are similar to a vibrating reed. Passageways narrowed almost to closure.

  • Wheeze high, Sibilant
  • airway obstruction, chronic emphysema

43

Name this adventitious sound

Crackles fine

44

This is a high pitched short crackling w/ popping sounds. Heard during inspiration.  Cough does NOT clear it

  • Crackles Fine
  • pneumonia, heart failure, i.fibrosis, c.bronchitis, asthma

45

Name this adventitious sound pattern

Atelactic Crackles

46

This is a loud low pitched bubbling & gurgling. Starts in early inspiration. Sounds like a velcro fastener. Inhaled air is colliding with secretions in the trachea and large bronchi.

  • Crackles Course
  • pulmonary edema, pneumonia, depressed cough reflex

47

This sounds like fine crackles but do not LAST. They are not pathologic. It is when section of alveoli do not aerate. Deflate and accumulate secretions.

  • Atelactic Crackles (rales)
  • bedridden pateint

48

Name this adventitious sound pattern?

Pleural Friction Rub

49

This is a very superficial sound that is course and low. Like 2 pieces of leather are being rubbed together.  Loss of lubricating fluid. Heard best in anterolateral wall.

  • Pleural Friction Rub
  • painful to breathe

50

Name this adventitious sound pattern

Wheeze Low pitch (sonorous ronchi)

51

You will hear a single note. Snoaring or moaning sounds. May clear a little by coughing.  It is caused by airflow obstruction.

  • Wheeze low pitched (sonorous)
  • bronchitis, airway ob tumor

52

Characteristics of S1

  • First heart sound
  • Closure of the AV valves
  • "Lub"
  • heard best at the apex
  • Beginning of systole

53

Characteristics of S2

  • Second heart sound
  • closure of semilunar valves
  • "Dub"
  • End of Systole
  • heart at Base of heart

54

Where is S1 louder than S2

at the apex

55

Which artery does S1 coincide with?

carotid

56

Which wave does S1 coincide with on ECG?

R-wave

57

Characteristics of S3

  • Vibrations from filling ventricles
  • "lub-dubba" "kentucky"
  • Early diastole, after S2
  • At apex with bell
  • left lateral position

58

Characteristics of S4

  • Blood being pushed into a noncompliant ventricle
  • "da-lub-dub" "Tennessee"
  • End of diastole, presystole, before S1
  • Heard at apex with bell

59

Characteristics of a Murmur

  • Turbulent blood flow and collision currents
  • "swooshing"
  • structural defects in valves, unusual opening in chambers, anemia.
  • Heard best at Chest Wall

60

What data are you gathering during Auscultation of Heart Sounds x5

  1. Rate / Rhythm
  2. Identify S1 & S2 (together)
  3. S1 & S2 (separate)
  4. S3 & S4
  5. Murmurs

61

What are you listening for with murmurs?

  • Timing
  • Loudness
  • Ptich
  • Pattern
  • Quality
  • Location
  • Radiation
  • Posture/Position

62

All Patients Take Meds..

  • Aortic (2nd Rt, ICS)
  • Pulmonary (2nd Left, ICS)
  • Tricuspid (Lt lower sternum)
  • Mitral (5th ICS midclavical)

63

Step 1: Blood has cicrulationg through the body, lost its oxygen and collected CO2, where does it enter?

  • Right Atrium of the heart through the Vena Cava

64

Step 2: Right Atrium Contracts and pumps blood through which valves?

Tricuspid valve and right ventricle

65

Step 3 of 9: The Right Ventricle pumps blood where?

  • Through the pulmonary artery into the lungs

66

 Step 4: What do the tiny blood vessels (capillaries) in the lungs do?

 

absorb CO2 from blood and replace it with oxygen

67

Step 5: oxygenated blood flows through the pulmonary vein and into where?

  • Left Atrium

68

Step 6: Oxygenated blood pumps throu the mitral valve and into where?

Left Ventricle

69

Once the blood has gone through the aortic arch, what are the option for where blood can be pumped?

  • thru carotid artery into the brain
  • auxiliary arteries into the arms
  • aorta and into the torso/legs

70

Step 8: Blood moves through the arteries, then through capillaries, where does it return?

Veins

71

Step 9: What is the last step of the cardiac cycle?

Deoxygenated blood will return to the heart

72

this pumps blood to pulmonary circulation

right ventricle

73

pumps blood to the systemic circulation

 

left ventricle

74

this is a valve between LA & LV

Mitral Valve

75

Valve betwee RV & Pulmonary Aorta

pulmonic valve

76

This drains arms

subclavian vein

77

Organ in LUQ of the adomen that produces lymphocytes and monocytes

spleen

78

What is valsavle maneuver?

  • bearing down
  • lead to herniated disc
  • tumor

79

This is a palpable vibration while patient says "blue moon"

fremitus

80

Where do sounds for tactile fremitus originate?

  • Generated from larynx >  patent bronchi > lung parenchyma > chest wall (where you feel them)

81

Unequal chest expansion occurs with x4

  1. marked atelectasis;

  2. pneumonia;

  3. thoracic trauma;

  4. pneumothorax

82

This is soft, muffled thud; signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis or tumor

Dull

83

When does the apical impulse increase in size and duration?

  • anxiety,
  • fever,
  • hyperthyroidism
  • anemia

84

this is felt over the precordium during systole in aortic stenosis, pulmonary stenosis, and ventricular septal defect.

systolic thrill

85

This is when ventricular filling creates vibrations

S3

86

Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention Enema by doing which of the following?

A) Administering a large volume solution 500 to 1000 ml
B) Mixing milk and molasses and equal parts for an enema
C) Instructing the patient to retain the enema for at least 30 seconds
D) Administering the enema while the patient is sitting on a toilet

c) Instructing the patient to retain the enema for at least 30 sec

87

During removal of a fecal impaction, which of the following could occur Because of vaginal stimulation?
A) Bradycardia
B)Atelectasid
C) Tachycardia
D) Cardiac tamponade

A) Bradycardia

Removing a fecal impaction manually may result in stimulation of the vaginal nerve and resulting bradycardia

88

What is the incidence of deep vein thrombosis?

Age-dependent
In a 50yo: 1/1,000 per year
Young adults: 1/10,000 per year
In elderly: 1/100 per year

89

What are the signs and symptoms of DVT?

  • Distension of surface veins,
  • pain/tenderness,
  • redness/discolouration,
  • swelling,
  • warmth

90

What are subjective assessment questions for Cardiac x8

  • chest pain
  • cough
  • shortness of breath
  • swelling in feet or legs
  • facial skin color
  • fatigued
  • family history of heart disease
  • use more than one pillow

91

This is a condition in which one or more areas of your lungs collapse or don't inflate properly.

Atelactic

92

Pathological Reasons for Listening for S3

Anemia,
sign of HF
Volume overload
hyperthyroidism
pregnancy
renal failure
persists when sitting up

93

Reasons for listenting for S4

decreased compliance of ventricle
systolic overload
aortic stenosis
systemic hypertension

94

What are reasons for having a murmur

During menstrual cycle (benign)
During Exercise
Thyroid level too high
Anemia (low blood)-less rbcs, less oxygen
expected for infants
structural defects in valve
unusual openings in chambers

95

What happens heart/neck when Aging?

BP increases
lifestyles
sodium
Left ventricle increases
Increase Arrhythmias
Orthostatic Hypotension (getting out of bed fast)
check for bruits in carotid
systolic heart murmur

96

Where do you assess an adult heart

 

5th ICS

97

Where do you assess infant heart?

3-4 ICS

98

High risk factors for heart disease

high blood pressure
smoking
high cholesterol
diabetes
obesity

99

Intraluminal valves help to ensure

blood moves towards the heart

100

What do varicose veins look like?

blue
torturous
you can fee

101

How would the skin present itself if you had arterial insufficiencies?

thin, shiny skin, thick nails
less hair on legs

102

Which lung lobe is shorter?

the right side, because of the liver

103

What is visceral pleura

sack for the lungs

104

What does negative pressure mean referring to the lungs

lungs are being pulled open, otherwise lungs would collapse

105

Where does gas exchange occur?

bronchial trees

106

What is Hypercapnea

too much CO2

107

Is expiration passive or active?

Passive

108

What are discontinuous sounds?

  • crackles
  • atelectic crackles
  • pleural friction rub

109

What are continuous sounds

 

wheeze, stridor

110

What do stretch receptors initiate

contraction of sigmoid colon/rectal muscles

111

What can accompany a murmur?

a thrill

112

What does a thrill signify?

stenosis or hypertension

113

What is a heave or lift?

sustained forceful thrusting of ventricle during systole

114

Where can a right heave be seen

sternal border

115

Where is a left heave seen?

at the apex

116

What can a bruit indicate?

hyperplasia of the thyroid,

117

Characteristics of Split S2

  • happens during inspiration but NOT while holding breath
  • in the pulmonic area

118

Cardiac assessment for infant (subj)

  • mother during prego
  • cyanosis
  • growth as expected?
  • play w/o tiring?
  • naps per day, how long?

119

Cardiac assessment for child (subj)

  • growth as expected?
  • keeping up?
  • rest during play?
  • joint pain
  • headaches/nosebleeds
  • respiratory infection
  • siblings w/ defects

120

Where do you assess pulses?

  • Temporal Artery
  • Carotid Artery
  • Brachial/Ulnar/Radial
  • Legs

121

What is the difference for children vs adults with lymph nodes?

  • enlarge in children
  • atrophy in adults

122

What is the function of lymphatics

retrieve excess fluid from tissue spaces and return to bloodstream

123

What does Venous Insufficiency look like?

  • wet
  • darker skin pigmentation

124

What does Arterial Insufficiency look like?

  • light color
  • dry
  • leg cramping

125

Difficulty swallowing

dysphasia

126

What are systemic changes with decreased oxygen?

  1. clubbing
  2. hair loss
  3. hypoxic
  4. hypoxemia

127

What is WOB

  • work of breathing

128

What do you inspect for the lungs?

  • shape, AP:T Ratio
  • Nails
  • Position
  • WOB
  • Skin Color

129

What causes decrease breath sounds?

COPD & mucous

130

What causes increased breath sounds

pneumonia

131

What position do you place patient for an enema

left lying lateral

132

How much fluid can an average adult handle for an enema?

  • 350-500 ML

133

Characteristics of Small Intestine

  • absorption of nutrients and electrolytes
  • 20' long

134

Name the 3 sections of the small intestine

  1. Duodenum
  2. Jejunum
  3. Ileum

135

Name the characteristics of the large intestine

  • 5-6 ft long
  • Elimination
  • absorbs water/electrolytes

136

Name the 4 sections of the large intestine

  1. ascending
  2. transverse
  3. descending
  4. sigmoid

137

What does the midsection of the thoracic cavity contain?

  • Esophagus
  • Trachea
  • Heart
  • Great vessels

138

The nurse recognizes that the administration of a drug influences cell physiology. What is the term for this concept?

Pharmacodynamics

139

the study of what the body does to the drug

Pharmacokinetics