Exam 2: NR414 REV Flashcards
(222 cards)
1
Q
This is grinding of the teeth expecially at night
A
Bruxism
2
Q
Smooth Glossy tongue that occurs with pernicious anemia
A
Atrophic Glossitis
3
Q
This is a fungal infections, commonly called thrush in new borns
A
Candidiasis
4
Q
This is a term for “dry mouth”
A
Xerostomia
5
Q
A tumor caused by infection with human herpesvirus. It is the most common lesion seen in people wit AIDS
A
Kaposi’s Sarcoma
6
Q
This is a fungal infection of the tongue. A temporary, harmless oral condition that gives your tongue a dark, furry appearance.
A
Black hairy tongue
7
Q
Crcking erythema and painful fissures at the corners of the mouth that occur with excess salivation.
A
Cheilitis
8
Q
Smooth, pale gray nodules that are overgrowths of mucosa.
A
Polyps
9
Q
Another name for nosebleed
A
Epistaxis
10
Q
Another name for runny nose
A
Rhinorrhea
11
Q
a nontender, fibrous nodule in the gum between teeth
A
Epulis
12
Q
painless enlargement of the gums, sometimes overreaching the teeth.
A
Gingival hyperplasia
13
Q
Gum margins are red, swollen, and bleed easily, usually due to poor hygeine or vitamin C deficiency
A
Gingivitis
14
Q
Another name for a canker sore. (painful, open sore in the mouth. Canker sores are white or yellow and surrounded by a bright red area.)
A
Aphthous Ulcers
15
Q
Another name for cold sores
A
Herpes Simplex 1
16
Q
decrease mobility of the tongue tip
A
Ankyloglossia
17
Q
Chalky, white, thick, raised patch with well defined borders.
A
Leukoplasia
18
Q
Jarvis:
How does atrial systole occur?
A
independently of ventricular function
19
Q
Jarvis:
The second heart sound is the result of:
A
closing of the mitral and tricuspid valves
20
Q
Jarvis:
When palpating an apical impulse what is the normal size?
A
2 cm
21
Q
Jarvis:
Where do you listen in the pulmonic valve area?
A
the 2nd Left Interspace
22
Q
Jarvis:
What is the difference between S2 & S3?
A
S3 is lower pitched and is heard at the apex
23
Q
Jarvis:
When auscultating the heart your first step is to:
A
identify S1 & S2
24
Q
Jarvis:
Where is a split S2 heard most clearly?
A
pulmonic
25
Jarvis:
Why is the stethoscope placed lighting against the skin?
it does not act as a diaphragm
26
Jarvis:
What is the function of the venous system?
Hold more blood when blood volume increases
27
Jarvis:
What organs aid the lymphatic system?
spleen, tonsils, thymus
28
Jarvis:
What causes varicose veins in pregnant women?
pressure of the growing uterus on the veins
29
Jarvis:
A 4+ edema of the right leg is documents. The best description of theis type of edema is:
very deep pitting, indentation lasts a long time
30
Jarvis:
A known risk for venous ulcer development is:
obesity
31
Jarvis:
What does Brawny mean?
non pitting edema
32
The most common site of nosebleeds
Kiesselbach Plexus
33
Which sinuses can we physically examine
Frontal, Maxillary
34
This is the midline fold of tissue that connects the gongue to the floor of the mouth
Frenulum
35
Where are the largest salivary glands located?
Within the cheeks in front of the ear
36
What is a common cause of dry mouth?
medications
37
the bone and cartilage that divide the nasal cavity of the nose in half -- is significantly off center, or crooked, making breathing difficult
**Deviated Septum**. Document in case patient needs to be suctions
38
Where is the most common locations for oral malignancies to occur
_under the tongue_. "Mucosal Gutter"
39
In a medical reocord, the tonisl are grades as 3+. The tonsils would be located where?
touching the uvula
40
What is the function of the nasal turbinates?
Warm the inhaled air
41
The opening of an adult's partodi gland (Stenson's Duct) is opposite the:
upper 2nd molar
42
How can you tell the difference between a nasal polyp and a nasal turbinate?
* A polyp is:
1. movable
2. pale and gray in color
3. nontender
43
What are epistein pearls?
* small round, white shiny papules on the hard palate and gums of 2 month old.
44
What should you **palpate** when examiniong the tongue
the U shaped area **under** the tongue
45
What is the manubriosternal angle
the articulation of the manubrium and the body of the sternum
46
Which side of the lungs is narrower and only has 2 sides
Left lung
47
What are signs of chronic bronchitis?
* cough for at least 3 months of the year
* 2 years in a row
48
Where do you asses for symmetric chest expansion
* place hands on posterolateral chest wall
* thums at the level of T9 or T10
* slide hands up to pinch up a small fold of skin
49
Absence of diaphtramatic excursion (breathing) occurs with...
Pleural effusion or atelectasis of the lower lobes
50
Where do you auscultate for breath sounds
* hold diaphragm of steh against chest wall
* listen to 1 full respiration in each location
* compare Side to Side
51
This breath sound is moderate in pitch, inspiration= expiration
Bronchovesicular breath sounds
52
What is the diagnosis:
Increase respiratory rate, chest expansion decreased on left side, dull percussion over left lower lobe. Breath sounds with crackles over left lobe.
Lobar Pneumonia
53
In a physical assessment what is a symptom of chronic congenital heart disease and COPD
* nail base \>160 degrees
* base feels spongy to palpate
54
Patient complains of pain with breathing. You note low pitched sound during both inspiration and expiration.
Pleural Friction Rub
55
"99", "Blue", "EEEE"
egophony technique while moving stethoscope
56
This tool measures arterial oxygen saturation
pulse oximeter
57
Which assessment technique is best utilized for examing a pleural friction rub
auscultation
58
Where is the apex of the lung located?
* 3 to 4 cm above the inner third of the clavicels
59
Where is the base of the lung?
Rests on the diaphragm
60
Where is the left lateral lung located?
* sixth rib, midclavicular line
61
Where is the Right Lateral Lung Border?
Fifth intercostal
62
Where is the posterior apex of the lung border?
C7
63
How is a normal chest shaped?
elliptical shape with an anteroposterior transverse diameter. Ratio 1:2
64
Anteroposterior means
65
How is a barrell chest shaped
Anteroposterior = transverse diameter
66
How is pectus excavatum shaped?
sunken sternum and ajacent cartilages
67
How is pectus carniatum shaped?
forward protrusion of the sternum with ribs sloping back at either side
68
How is scoliosis shaped?
lateral S shaped Curvature of the thoracic and lumbar spine
69
Exaggerated posterior curvature of the spine
Kyphosis
70
Bronchial Tracheal Characteristics:
* High pitched
* Inspiration
* Harsh,Hollow, Tubular
* *Trachea/Larynx*
71
72
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
73
This breath sound is over peripheral lung fields where air flows through smaller bronchioles and alveoli
Vesicular
74
Characteristics of Vesicular Sounds
* Low pitch
* inspiration \> Expiration
* Rustling like wind in trees
75
What is the name for this respiration pattern?
Sigh
76
This is purposeful and expands the alveoli. May indicate emotional dysfunction and could lead to hyperventilation.
Sigh
77
Name this respiration pattern
Biot's Respiration
78
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*
79
Name this respiration pattern?
Normal Adult
80
Rate is usually 10-20 breaths/min. Depth 500-800ml. Pattern is even.
Normal Adult
81
Name this respiration pattern?
Cheyne Stokes
82
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*
83
Name this respiration pattern
Tachypnea
84
Rapid shallow breathing. \>24/min.
* Tachypnea
* *exercise, fever, fear, pneumonia*
85
Name this respiration pattern
Bradypnea
86
Slow breathing,
* Bradypnea
* *drug induced*
* *diabetic coma*
87
Name this respiration pattern
hyperventilation
88
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*
89
Name this respiration pattern
Chronic Obstructive Breathing
90
This is when you have prolonged expiration to overcome airway resistance.
* Chronic Obstructive Breathing
* *can cause air trapping (dyspneic episode)*
91
Name this respiration pattern
Hypoventilation
92
An irregular shallow pattern of breathing caused by an OD of narcotics, anesthetics or prolonged bed rest.
* Hypoventilation
93
What does adventitious sounds mean?
Abnormal
94
Name this adventitious sound pattern
Stridor
95
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.*
96
Name this adventitious sound pattern
97
Name this adventitious inhalation pattern
Wheeze high pitched (sibilant
98
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*
99
Name this adventitious sound
Crackles fine
100
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*
101
Name this adventitious sound pattern
Atelactic Crackles
102
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*
103
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*
104
Name this adventitious sound pattern?
Pleural Friction Rub
105
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*
106
Name this adventitious sound pattern
Wheeze Low pitch (sonorous ronchi)
107
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
108
109
Characteristics of S1
* First heart sound
* Closure of the AV valves
* "Lub"
* heard best at the *apex*
* Beginning of systole
110
Characteristics of S2
* Second heart sound
* closure of semilunar valves
* "Dub"
* End of Systole
* heart at Base of heart
111
Where is S1 louder than S2
at the apex
112
Which artery does S1 coincide with?
carotid
113
Which wave does S1 coincide with on ECG?
R-wave
114
Characteristics of S3
* Vibrations from filling ventricles
* "lub-dubba" "kentucky"
* Early diastole, after S2
* At apex with **bell**
* left lateral position
115
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**
116
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
117
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
118
What is the formula for pulse deficit
apical rate - radial rate
119
What are you listening for with murmurs?
* Timing
* Loudness
* Ptich
* Pattern
* Quality
* Location
* Radiation
* Posture/Position
120
If you hear a swooshin sound during diastolic sounds, what does that indicate?
Heart Disease
121
All Patients Take Meds..
* Aortic *(2nd Rt, ICS)*
* Pulmonary *(2nd Left, ICS)*
* Tricuspid *(Lt lower sternum)*
* Mitral *(5th ICS midclavical)*
122
What are the 2 phases of the Cardiac Cycle?
1. Diastole: relax, filling, Atrial Kick
2. Systole: blood pumped out
123
Documenting Heart Sounds x4
1. Frequency/Pitch
2. Intensity/Loudness
3. Duration
4. Timing: systole/diastole
124
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
125
Step 2: Right Atrium Contracts and pumps blood through which valves?
Tricuspid valve and right ventricle
126
Step 3 of 9: The Right Ventricle pumps blood where?
* Through the pulmonary artery into the lungs
127
Step 4: What do the tiny blood vessels (capillaries) in the lungs do?
absorb CO2 from blood and replace it with oxygen
128
Step 5: oxygenated blood flows through the pulmonary vein and into where?
* Left Atrium
129
Step 6: Oxygenated blood pumps throu the mitral valve and into where?
Left Ventricle
130
Which side of the heart contracts the strongest?
the Left Side
131
Why does the left side contract the strongest?
* To send blood out the left ventricle and through the aortic arch and on its way to al parts of the body.
132
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
133
Step 8: Blood moves through the arteries, then through capillaries, where does it return?
Veins
134
Step 9: What is the last step of the cardiac cycle?
Deoxygenated blood will return to the heart
135
Myocardium
Muscle layer of the heart
136
Smooth **inner** layer of the heart
Endocardium
137
Between parietal and visceral layer
pericardial space
138
This is the pacemaker of the heart with 60-100 bpm
sinoatrial node
139
Major vein of the head
* jugular
* *drains the head*
140
Major artery that supplies blood to the head
carotid
141
this pumps blood to pulmonary circulation
right ventricle
142
pumps blood to the systemic circulation
left ventricle
143
this is a valve between LA & LV
Mitral Valve
144
Valve betwee RV & Pulmonary Aorta
pulmonic valve
145
Paces Heart at 40-60 BPM
AV Node
146
This is lymphatic tissue found in the oropharynx
Tonsils
147
This drains arms
subclavian vein
148
Organ in LUQ of the adomen that produces lymphocytes and monocytes
spleen
149
These veins drain the legs
iliac
150
This is lyphatic tissue in thorax that helps w/ T-Cell differentiation
Thymus
151
What does the external sphincter do?
Relaxes
152
What is valsavle maneuver?
* bearing down
* lead to herniated disc
* tumor
153
Where do you assess potency of the nostrils?
CN1, olfactory
154
This is a palpable vibration while patient says "blue moon"
fremitus
155
Where do sounds for tactile fremitus originate?
* Generated from **larynx** \> patent bronchi \> lung parenchyma \> chest wall (where you feel them)
156
Unequal chest expansion occurs with x4
1. marked atelectasis;
2. pneumonia;
3. thoracic trauma;
4. pneumothorax
157
This is coarse, crackling sensation palpable over the skin surface. Occurs in subcutaneous emphysema, when air escapes from the lungs and enters the subcutaneous tissue
Crepitus
158
This is soft, muffled thud; signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis or tumor
Dull
159
this is lower pitched, booming sound found when too much air is present, as in emphysema or pneumothorax
Hyperesonance
160
Occurs with compression or consolidation of lung tissue (e.g. lobar pneumonia) Present only when the bronchus is patent and when the consolidation extends to the lung surface.
Increased Fremitus
161
Occurs when anything obstructs transmission of vibrations. (e.g. obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema.
decreased fremitus
162
When could the apical impulse not be palpable
obese persons, or persons with thick chest walls.
163
When does the apical impulse increase in size and duration?
* anxiety,
* fever,
* hyperthyroidism
* anemia
164
This is a palpable vibration. It feels like a throat of a purring cat. Usually signifies turbulent blood flow with loud murmurs.
Thrill
165
this is felt over the precordium during systole in aortic stenosis, pulmonary stenosis, and ventricular septal defect.
systolic thrill
166
sometimes felt on percussing over a cyst.
hydatid thrill
167
this is felt over the precordium during ventricular diastole in **advanced aortic insufficiency.**
diastolic thrill
168
This is when ventricular filling creates vibrations
S3
169
Signs/Symptoms of DVT
* pain, swelling, tenderness in one of your legs (calf)
* warm skin where clot is located
* redness back of your leg below knee
* aching
170
Wha are reasons to administer an enema?
1. Constipation
2. Bowel preparation for procedures
171
While administering an enema you feel resistance, what is the appropriate nursing action?
Stop the procedure and notify the healthcare provider
172
What is the typical amount of time a client can hold the fluid in after an enema before expelling it?
2-5 minutes
173
When administering a regular enema, how high should you hold the enema bag?
12 inches
174
What is the correct thing to do if a clinet complains of cramping during the enema administration?
Lower the height of the enema bag
175
*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
176
*Your patient complains of an excessive flatulence. When reviewing your patients dietary intake, which foods, if eaten regularly, would you identify as possibly responsible?*
A) Meet
B) Cauliflower
C) Potatoes
D) Ice cream
B) Cauliflower
Cauliflower is a gas producing food that relates in flatulence
177
*Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this?*
A) They will cause a fecal impaction
B) They will cause chronic constipation
C) They change the pH of the Gastrointestinal track
D) They inhibit the intestinal enzymes
B) Chronic constipation
178
*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
179
*Which of the following is an appropriate nursing action to promote regular bowel habits?*
A) Encourage the patient to avoid moving his bowels until a certain time of day
B) Encourage the patient to avoid excess fluid intake and too much fiber
C) Avoid strenuous exercise to limit stress on the abdominal muscles and impair peristalsis
D) Assisting the patient to a normal position as possible to defecate
D) Assisting the patient to a normal **position** as possible to defecate
Sitting upright on a toilet or commode promotes defecation. If the patient must use a bedpan, raise the head of the bed 30 to 45°. Patient should be encouraged to move their bowels at their usual time of the day.
180
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
181
What are the risk factors for DVT?
* obesity,
* cancers,
* major surgery,
* infection,
* chemotherapy,
* IV drug use,
* inacitivty and immobility,
* post-partum period,
* long-haul flights
182
What are the signs and symptoms of DVT?
* Distension of surface veins,
* pain/tenderness,
* redness/discolouration,
* swelling,
* warmth
183
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
184
This is a condition in which one or more areas of your lungs collapse or don't inflate properly.
Atelactic
185
What can cause infection in the Cardiac
* bad gums
* central line
* weak valve
* inflammation
186
Listening to the heart, what side of your stethoscope do you hear low pitched sounds?
The bell
187
What is a bruit?
turbulent blood flow
188
Pathological Reasons for Listening for S3
Anemia,
sign of HF
Volume overload
hyperthyroidism
pregnancy
renal failure
persists when sitting up
189
Reasons for listenting for S4
decreased compliance of ventricle
systolic overload
aortic stenosis
systemic hypertension
190
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
191
What is a resting adult CO
4-6 of blood/min
192
What is preload?
force of stretch in heart from venous return
193
What is afterload?
Ventricular pressure needed to eject blood
194
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
195
Where do you assess an adult heart
5th ICS
196
Where do you assess infant heart?
3-4 ICS
197
What is PMI referring to?
Point of Maximal Impulse
198
High risk factors for heart disease
high blood pressure
smoking
high cholesterol
diabetes
obesity
199
what type of assessment do you take for bruit?
Auscultate
200
201
What do blood vessels do?
transports blood which transports oxygen
202
What are you markers for major arteries?
ulnar, radial, brachial
203
Intraluminal valves help to ensure
blood moves towards the heart
204
What do varicose veins look like?
blue
torturous
you can fee
205
How would the skin present itself if you had arterial insufficiencies?
thin, shiny skin, thick nails
less hair on legs
206
used to evaluate the adequacy of collateral circulation prior to cannulating the radial artery;
Modified Allens Test
207
What and where are you looking for during a modified allens test?
* should see blanching
* compression on radial & ulnar arterties
208
Which lung lobe is shorter?
the right side, because of the liver
209
What is visceral pleura
sack for the lungs
210
What does negative pressure mean referring to the lungs
lungs are being pulled open, otherwise lungs would collapse
211
Where does gas exchange occur?
bronchial trees
212
What is controlling respiration
CO2
213
What is Hypercapnea
too much CO2
214
hypoxemia
low oxygen in the blood
215
What is the major muscle of inspiration
diaphram
216
Is expiration passive or active?
Passive
217
What causes crackles?
Too much fluid
218
What are discontinuous sounds?
* crackles
* atelectic crackles
* pleural friction rub
219
What are continuous sounds
wheeze, stridor
220
What type of breath sound is asthma
wheeze
221
What are 3 salivary glands
* parotid
* submandibula
* sublingua
222
What do stretch receptors initiate
contraction of sigmoid colon/rectal muscles
