Exam 2: NR414 Rev 2 Flashcards
(138 cards)
1
Q
This is a term for “dry mouth”
A
Xerostomia
2
Q
Another name for nosebleed
A
Epistaxis
3
Q
Jarvis:
The second heart sound is the result of:
A
closing of the mitral and tricuspid valves
4
Q
Jarvis:
When palpating an apical impulse what is the normal size?
A
2 cm
5
Q
Jarvis:
Where do you listen in the pulmonic valve area?
A
the 2nd Left Interspace
6
Q
Jarvis:
What is the difference between S2 & S3?
A
S3 is lower pitched and is heard at the apex
7
Q
Jarvis:
When auscultating the heart your first step is to:
A
identify S1 & S2
8
Q
Jarvis:
Where is a split S2 heard most clearly?
A
pulmonic
9
Q
The most common site of nosebleeds
A
Kiesselbach Plexus
10
Q
What is a common cause of dry mouth?
A
medications
11
Q
Which side of the lungs is narrower and only has 2 sides
A
Left lung
12
Q
This breath sound is moderate in pitch, inspiration= expiration
A
Bronchovesicular breath sounds
13
Q
Where is the left lateral lung located?
A
- sixth rib, midclavicular line
14
Q
Where is the Right Lateral Lung Border?
A
Fifth intercostal
15
Q
Where is the posterior apex of the lung border?
A
C7
16
Q
Bronchial Tracheal Characteristics:
A
- High pitched
- Inspiration
- Harsh,Hollow, Tubular
- Trachea/Larynx
17
Q
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
A
Bronchovesicular
18
Q
This breath sound is over peripheral lung fields where air flows through smaller bronchioles and alveoli
A
Vesicular
19
Q
Characteristics of Vesicular Sounds
A
- Low pitch
- inspiration > Expiration
- Rustling like wind in trees
20
Q
This is purposeful and expands the alveoli. May indicate emotional dysfunction and could lead to hyperventilation.
A
Sigh
21
Q
Name this respiration pattern
A
Biot’s Respiration
22
Q
This is a series of normal respiration followed by a period of apnea. Cycle is variable, lasting from 10- 60 sec.
A
- Biots Respiration (irregular)
- Seen with head trauma, brain abscess, heat stroke spinal meningitis, & encephalitis
23
Q
Name this respiration pattern?
A
Normal Adult
24
Q
Rate is usually 10-20 breaths/min. Depth 500-800ml. Pattern is even.
A
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
