Exam 2 Revised Flashcards
(136 cards)
1
Q
Describe wheezing
A
Whistling, high-pitched, from air moving in narrow pathways, can be present on inspiration and/or expiration
2
Q
What can narrow passage ways to cause wheezing?
A
Allergens, edema of the bronchioles
3
Q
What processes are associated with wheezing?
A
COPD, asthma, bronchitis, emphysema
4
Q
Describe rhonci
A
Continuous
* Low pitch
* Snoring sound
* Present on inspiration and expiration
5
Q
What causes rhonchi? (Not disease processes)
A
Due to fluid, mucous or growth in larger airways (May clear with cough)
6
Q
What processes are associated with rhonchi?
A
Pneumonia, COPD, Bronchitis
7
Q
Describe crackles (rales)
A
Intermittent
* Rattling, Crackling, Popping, or Bubbling
* May be fine and high or course and low pitched.
* Do not clear with cough
8
Q
What causes crackles? (not disease processes)
A
Due to lung conditions that cause Fluid, Inflammation, or Consolidation in the alveoli
* This takes up space in the alveoli that is not fully inflated
Fluid volume overload
9
Q
What are associated disease processes for crackles?
A
Associated disease process:
* Fine Crackles: Fibrosis, pneumonia, heart failure, Asthma or COPD
* Coarse Crackles: Fibrosis, pneumonia, pulmonary edema, COPD
10
Q
Differentiate fine vs course crackles
A
Fine crackles
* End of inspiration
Course Crackles
* During inspiration
* Very loud
11
Q
Describe pleural friction rub
A
Low pitch
* Course, grating tone like rubbing 2 pieces of leather together.
* Very painful
Worse with inspiration
12
Q
What causes pleural friction rub? (not the disease processes)
A
Due to inflamed pleura what has lost normal lubrication
13
Q
What processes are pleural friction rub associated with?
A
Associated disease process:
* Pleuritis or Pleurisy
14
Q
Describe stridor
A
High pitch crowing sound heard without a scope
* May be life-threatening. This is an EMERGENCY
15
Q
What causes stridor?
A
Due to upper airway obstruction
16
Q
What disease processes are associated with stridor?
A
Associated disease process:
* Inflammation (RSV)
* Foreign body
* Epiglottitis
* Croup
17
Q
Describe tracheal breath sounds
A
Very loud, high pitched. Expiration and inspiration sounds are equal.
18
Q
Where are tracheal sounds heard?
A
Over the trachea
19
Q
Describe bronchial sounds
A
Loud, relatively high-pitched. Inspiration is shorter than expiration.
20
Q
Where do you hear bronchial sounds?
A
Over the manubrim. (just above clavicle)
21
Q
Describe bronchovesicular sounds
A
Medium loudness, intermediate pitch. Inspiration and expiration equal
22
Q
Where do you hear bronchovesicular sounds?
A
1st and 2nd intercostal space.
23
Q
Describe vesicular sounds
A
Soft and low pitch. Inspiration longer then expiration.
24
Q
Where can you hear vesicular sounds?
A
Most of the lung field
25
What are risk factors for Coronary Artery Disease (CAD) and Peripheral Artery Disease (PAD)?
smoking, diabetes, hypertension, hypercholesterolemia, and family history of arterial problems.
26
What are risk factors for DVT?
smoking, hypertension, diabetes, and obesity
27
What are risk factors for CVI?
(Chronic Venous Insufficiency)
age, being female, family history of CVI, leg injuries, obesity, phlebitis, and pregnancy. Can result from a DVT as well.
28
What is intermittent claudication?
Pain brought on by exertion and relieved by rest. It usually indicates arterial blockage.
29
What are the symptoms of intermittent claudication?
struggling to walk long distances, cramping, cool temperature, blue or pale color, may lead to ulcers. Think of your 7ps for this too.
30
What are the locations of each cardiac listening point?
Aortic: 2nd intercostal space (right)
Pulmonary: 2nd intercostal space (left)
Erb's point: 3rd intercostal space (left)
Tricuspid: 4th intercostal space (left)
Mitral (PMI): 5th intercostal space and left midclavicular line
31
What are the names and locations of pulse points learned in lab?
Radial: between wrist bone and tendon on on thumb side of wrist
Posterior tibialis: inside of ankle
Dorsalis pedis: top of foot
Popliteal: behind the knee
Femoral: groin
32
How do we document findings related to pulses?
Pulses are graded on 0-+4 scale. Make sure you can palpate bilaterally.
33
How do we document findinds related to murmurs?
note if it is a systolic or diastolic murmur
34
What is a heart murmur usually connected to?
Valve issues
35
What is a major concern for patients with lymphadema?
High protein lymph fluid destroying tissue.
36
What should you NOT do for patients with lymphadema?
Take their blood pressure
37
What operation can cause lymphadema?
A mastectomy
38
What kind of occlusion is considered an emergency?
Acute arterial occlusion
39
Characteristics of people with a DVT or CVI?
blood is trapped and cannot get back. Usually heavy (weight of blood), dark, warm. If they have a DVT, it can have similar symptoms with pain.
You may can give a diuretic because it will help remove the fluid
40
What is the term for growing new arteries?
angiogenesis
41
What drug is typically ordered when there are abnormal lung sounds? What should you be aware of when giving this drug?
Diuretics. Be aware that this will make the patient go to the bathroom. This can cause orthostasis as well.
42
What respiratory changes occur to aging adults?
Respiratory strength declines
Lungs lose elasticity, flexibility decreases in cartilage or ribs, and bone density decreases
The anterior-to-posterior depth of the chest widens, causing the thorax to become more rounded or barrel shaped which makes it harder to inhale deeply
43
What cardiac changes occur to an aging adult?
Changes in pulse and BP (stiffening of blood vessels)
Increase in BMI
Elevated late diastolic filling increase volume of atrial contraction (S4 gallop)
Ventricle hypertrophy (heart failure and A-fib)
Watch for heart failure, weight gain, SOB, edema
More prone to atherosclerosis and CV disease
44
What peripheral vascular changes occur to an aging adult?
Arterial disease coupled with atherosclerosis
PAD frequently undiagnosed
Trophic nails changes, thin shiny skin, and hair loss of lower extremities
Decreased functional ability
Systolic hypertension
Chronic venous insufficiency
Venous thromboembolism
Varicose veins, stroke, MI, arteries more rigid
Nails are more brittle
Increase risk of DVT
45
What are expected findings for respiratory issues?
Chest pain/discomfort
Dysnpnea
Orthopnea/PND
Cough
Sputum or phlegm produced from cough
Wheezing or tightness in chest
Change in functional ability
46
What are risk factors for COPD?
second hand smoke, chronic bronchitis, aging, history of severe respiratory infections, poor socioeconomic status, asthmas and airway hyperactivity
47
What are symptoms of COPD?
May notice wheezes, clear sputum, and occasional hyper resonance in the assessment, labored breathing (accessory muscles), forced expiration, barrel chest
Usually in tripod position
48
What is the proper way to auscultate breath sounds?
Auscultate that trachea and anterior and lateral lung fields, beginning at trachea. Listen to lung apices, moving side to side (symmetry). Place around breasts in female. Listen to 6th ICS bilaterally or when sounds become absent.
49
What is the sequences of electrical conduction in the heart?
SA node, AV node, bundle of His, right and left bundle branches, Purkinje fibers
50
What is the HONEST hearts mnemonic?
- Heritage
O- Obesity
N- Nicotine
E- Exercise (lack of)
S-SBP > 140mmHg
S-Sugar greater than 130 or
dx of Diabetes
T- Triglycerides/LDL
51
What are the signs of left sided heart failure?
Chest pain, cough, fatigue, fluid retention in lungs.
52
What are s/s of right-sided heart failure?
Swelling in the legs, JVD, SOB, weight gain, chest pain, fatigue.
53
What interventions are used for heart failure?
For heart failure, leave out sodium in diet, smoking cessation, weigh every day, possible fluid restrictions.
54
What specific value helps to identify tachyarrhythmias? What vital sign can help tell?
Cardiac output and BP
55
How do you assess for jugular vein pulse?
Elevate head of bed to 30 degrees. Look at right side
Normal jugular vein: 3cm or less, or disappears
Abnormal: Greater then 3cm, JVD likely
56
Trace the blood flow through the heart
vena cava, right atrium, tricuspid valve, right ventricle, pulmonary valve, pulmonary artery, lungs, pulmonary vein, left atrium, mitral valve, left ventricle, aortic valve, aorta
57
How to properly document normal heart sounds?
normal rate and rhythm. S1 and S2 present
58
How to properly document abnormal heart sounds?
murmurs, rubs, gallops present
59
How to properly document normal lung sounds?
no crackles, wheezes, rhonchi, bronchophony, egophony, or pectoriloquy
60
How to properly document abnormal lung sounds?
expiratory crackles (fine or course) bilaterally in bases, positive bronchophony, egophony, pectoriloquy
61
How do you perform a carotid assessment?
Inspect for double stroke seen with S1 and S2
Palpate medial to sternomastoid muscle between jaw and clavicle. Avoid pressing on carotid sinus (bradycardia)
Auscultate with bell near the jaw, middle or neck, and near clavicle. Have patient hold their breath
62
What is a bruit and what does it mean?
Swooshing sounds similar to BP sounds. It means there is turbulent blood flow related to atherosclerosis. Artery is partially obstructed.
63
If you hear a bruit bilaterally in both carotids, what could possibly be the issue? What causes this issue?
There could be a bruit in the aorta that is radiating the sound to the arteries around it. This could be caused by traumatic anatomy or an occlusion.W
64
What is a murmur?
A murmur is a blowing or swooshing sound that occurs due to turbulent blood flow. Usually heard in systole or diastole in where higher blood velocities are (left ventricle and aorta)
65
When are S3 and S4 heard?
S3 is heard immediately after S2. Heard best in apex with patient lying on left side.
S4 is heard late in diastole immediately before S1.
66
What are the abnormal heart sounds?
Gallops (S3 and S4), rubs, and murmurs
67
What are the 7 p's?
pain, polar/poikilothermia, paresthesia, paralysis, pallor, pulselessness, perfusion
68
Characteristics of an arterial ulcer?
deep necrotic base, 7ps, associated with acute arterial occlusion, dry wound. defined borders, gangrene, eschar, slough, decreased or absent pulse
69
Characteristics of a venous ulcer?
superficial, pale, pain, edema, erythema, and warmth, irregular border, wet wound, weak pulse due to excess fluid
70
What is Raynaud's disease? What are the s/s?
Vasospastic disorder (vasoconstriction) that primarily affects women. Symptoms: numbness, tingling, sometimes pain, extreme pallor progressing to cyanosis, and coolness of the hands.
71
What does S3 indicate?
Heart failure. It is the result of fluid overload.
72
What conditions of the breast require further investigation?
New breast lump/Swelling
Existing lump with changes
Axillary lump
Skin irritation or dimpling
Nipple discharge
Nipple retraction
Breast or nipple Pain
73
What are some common breast and axillary symptoms?
Breast pain Rash Lumps; swelling Nipple discharge;
trauma
74
Is the following
statement true or false?
Analysis of assessment
and laboratory data help
clinicians identify the
underlying cause of
signs and symptoms.
True
Rationale: Analysis of assessment and laboratory data help clinicians identify the
underlying cause of signs and symptoms. Nurses use findings to identify the
underlying functional problem, label it (sometimes in a nursing diagnosis format),
and plan interventions based on patient outcomes.
75
Which of the following breast findings
do NOT need further evaluation?
-Lump that has changed
-Soft/Mobile lump
-New breast lump
-Bloody nipple discharge
-Fibroadenoma
-Lump in the axilla
-Slight breast asymmetry
Soft and mobile lump
Breast asymmetry
Fibroademoma
Rationale: Soft and mobile lumps typically represent a cystic
lesion, Slight breast asymmetry is not uncommon, fibroadenoma
is a benign breast tumors
76
What is breast tissue development in males?
Gynecomastia
77
What causes gynecomastia?
changing hormone levels in puberty. This is often
temporary
78
What are the most significant risks for breast cancer?
Female; over 50 years of age
Personal history of breast cancer
First-degree relative with breast cancer
79
What are some other risk factors for breast cancer (different from most significant risks)?
No children, or first child after 30 years of age
Menstruation before 12 years of age
Menopause after 55 years of age
Second-degree relative with breast cancer (aunt, grandmother)
High-fat diet and obesity
Alcohol intake of 1-2 drinks per day or more
Tobacco smoking
Oral contraceptive or estrogen replacement therapy
80
Describe breast changes in newborns/infants
Breast development in utero is not sex-specific. Breast enlargement can occur up until the age of 2 but usually resolves in a few months. Usually resolves spontaneously White discharge (witch's milk) can be present.
81
Describe breast changes in children/adolescents
Between the ages of 9 and 10 for females, changes in nipples, areole, and development of breast buds (breast budding) occur. Breast growth is stimulated mainly by estrogen but also progesterone. One breast can grow larger than the other but typically equals out. Breast growth begins during puberty.
82
Describe breast changes in older adults.
Glandular, alveolar, and globular tissues decrease. After menopause, fat deposits replace glandular tissue. Ovarian hormone levels decrease. Suspensory ligaments relax so breasts sag. Breasts decrease in size and lose elasticity. Nipples are smaller, flatter, and less erectile. Armpit hair stops growing.
83
Describe breast changes in pregnancy.
Breasts enlarge, duct system expands, and secretory alveoli develop. Nipples darken, enlarge, and become more erect. Montgomery glands develop. Bluish venous pattern develops. Can occur two months in.
84
How do you perform a self breast exam?
First visually look in the mirror with arms at sides for any changes in size or shape, dimpling, swelling, changes to the skin or any changes to the nipple. Next, with the flats of your 3 middle fingers, check the entire breast and armpit area, pressing down with light, medium, and firm pressure. Note any lumps, thickening, or knots. Then, lying down, use your left 3 middle fingers to palpate the entire right breast. Note any lumps, or thickenings, and squeeze the nipple for discharge. Repeat step for opposite breast.
In front of a mirror, press hands on hips to contract chest muscle to look for dimpling.
85
When do you perform a self breast exam pre menopause?
About day 7 of the menstrual cycle.
86
When do you perform a self breast exam post menopause?
The same day of each month
87
What interventions can be used for arterial disease?
Increase arterial blood flow, modify risk factors, anti platelet medications.
88
What interventions can be used for venous disease?
Prevent thrombus growth or travel, anticoagulants, promote venous return, compression, exercise
89
What are interventions for lymphadenopathy/lymphadema.
Promote lymphatic return, compression, exercise, elevation.
90
What are some common characteristics of ineffective tissue perfusion?
Reduced hair, thick nails, dry skin, weak or absent pulses, pale skin, coolness, reduced sensation, prolonged capillary refill.
91
What tissue provides support in the breast?
Fibrous
92
When causes lymph node enlargement?
Cancer and infection
93
What is orange-peel skin an indication of?
Breast cancer
94
Where can estrogen be produced from?
The ovaries and abdominal fat tissue.
95
How much exercise can reduce breast cancer?
15 minutes at least
96
What are goals related to risk reduction and health promotion of breasts?
Increase proportion of mothers who breastfeed, reduce female breast cancer death rate by 10%, reduce late stage female breast cancer.
97
What region has the highest risk of breast cancer?
North America
98
When the nurse assesses a 78-year-old patient with pneumonia, what is the priority assessment?
Breath sounds
Airway patency
Respiratory rate
Percussion sounds
Airway patency. Rationale: Consider the ABCs. Airway always assumes priority.
99
A 45-year-old male has been admitted to the hospital with suspicion of PE. Which of the following symptoms should the nurse report to the primary health practitioner immediately?
Chest pain
Shortness of breath
Respirations 20 breaths/min
Productive cough
Chest pain. Rationale: Chest pain is assumed to be heart pain and must be evaluated immediately, because heart cells die and do not regenerate. Ischemic heart pain, such as with a myocardial infarction, must be ruled out before considering another diagnosis. There is more time to treat shortness of breath, respirations of 20 breaths/min, and coughing.
100
A 62-year-old female comes to the clinic with an exacerbation of asthma. Which of the following findings indicate a diagnosis of asthma? Select all that apply.
Increased wheezing
Coarse rhonchi
Fever T 38°C orally
Oxygen saturation 90%
Increased wheezing and oxygen saturation 90%. Rationale: Wheezing is associated with the airway inflammation and narrowing that accompany asthma. Pulse oximetry less than 90% is associated with asthma and is a cause for concern and reason for immediate intervention. Coarse rhonchi indicate secretions in the airway such as pneumonia and are not expected with asthma. Fever T 38°C orally is a sign of infection found with pneumonia.
101
A 3-year-old child is brought to the ED with stridor, nasal flaring, intercostal and supraclavicular retractions, and respiratory rate of 40 breaths/min. What type of situation is this?
Stable
Acute
Urgent
Emergency
Emergency. Rationale: Stridor indicates upper airway obstruction and is considered an emergency. Because it is accompanied in this case by retractions and tachypnea, a rapid response may be indicated.
102
A 92-year-old female with a history of COPD presents with increasing shortness of breath, wheezing, no sputum, and 5-lb weight gain in 1 week. What is the most likely problem?
Impaired breathing
Impaired airway clearance
Activity intolerance
Overweight
Impaired breathing. Rationale: Patients with COPD often have both bronchitis and emphysema symptoms that impair breathing. If they have increased secretions and mucous, their airway can become impaired, but we do not have that data so far. We also need to gather more information about her functional and activity status. A weight gain of 5 lb in 1 week is more likely due to fluid retention than diet and calorie intake.
103
Which of the following factors is the most significant risk factor for COPD?
Increased age
Immune suppression
Tobacco smoking
Occupational exposure
Rationale: Smoking is the most common cause of COPD. It is a risk that should be assessed; assistance with smoking cessation should be offered. Immune suppression increases risk of pneumonia, increased age decreases functional reserves, and occupational exposure (such as paint or asbestos) can cause toxic injury.
104
When the nurse assesses a client with respiratory symptoms, which of the following complaints should be evaluated first?
Chest soreness
Dyspnea
Cough
Sputum
Dyspnea. Rationale: Shortness of breath is observed during the initial contact with the patient. These data assist in determining the acuity of the problem. Chest tenderness with palpation will be assessed during the history; sputum and lung sounds are assessed during the physical assessment.
105
When assessing a patient with atelectasis, what assessment findings are expected? Select all that apply.
Shortness of breath
Decreased breath sounds
Decreased oxygen saturation
Increased tactile fremitus
Hyperresonance
A, B, C, D. Shortness of breath, decreased breath sounds, decreased oxygen saturation, and increased tactile fremitus. Rationale: With atelectasis, the lung tissue has collapsed, which leads to less tissue for oxygenation. Consequently, the oxygen saturation is low, breath sounds are decreased, and the patient is short of breath. Because the tissue is consolidated, tactile fremitus is increased. The percussion sound might be dull, not hyperresonant, as a result of consolidation.
106
Which assessment findings would indicate that inhaled bronchodilators have been effective?
Expiratory wheezing, O2 saturation 94%, pallor
Vesicular breath sounds, O2 saturation 96%, pink
Bronchial breath sounds, O2 saturation 100%, erythema
Crackles, O2 saturation 90%, circumoral cyanosis
Vesicular breath sounds, O2 saturation 96%, pink. Rationale: If bronchodilators are effective, assessment findings would indicate adequate gas exchange. Abnormal findings include wheezing, low oxygen saturation, pallor, bronchial breath sounds, erythema, crackles, and cyanosis.
107
The nurse auscultates bronchovesicular breath sounds in the second ICS near the sternum. The nurse interprets this as
a normal finding over the trachea.
a normal finding over the bronchi.
an abnormal finding over the lung.
an abnormal finding over the trachea.
p. 478
A normal finding over the bronchi. Rationale: The trachea bifurcates at the second ICS, and bronchovesicular sounds are expected. Bronchial breath sounds are auscultated over the trachea; vesicular breath sounds are heard over the lung fields.
108
What are common complaints of a cardiac patient?
Chest Pain
Dyspnea, orthopnea, cough
Diaphoresis
Fatigue
Edema
Nocturia
Palpitations
Family History of CAD
Nicotine Use
109
What are common symptoms/complaints of respiratory patients?
Chest pain or discomfort
Dyspnea
Orthopnea or PND
Sputum (amount, color, odor, and viscosity)
Wheezing or tightness in chest
Change in functional ability
110
What is the correct chest ratio?
2:1
111
What is the chest ratio for barrel chested patients?
1:1
112
When are fine crackles heard?
The end of inspiration
113
When are coarse crackles heard?
During inspiraiton
114
What are risk factors for TB?
Exposure to an infected person
115
What is some subjective data for TB?
Nightsweats
116
What is the objective data for atalectasis?
Diminished breath sounds
117
What do mothers produce immediately after birth?
Colostrum
118
What is mastitis?
Infection of the breast tissue
119
Symptoms of mastitis?
Redness,warmth,pain,swelling increased WBC
120
How do you treat mastitis?
Antibiotics
121
What causes orange peel skin on breasts?
Blocked lymph
122
What does orange peel breast tissue look like?
Porous
123
What screening is used for breast cancer/isssues?
Mammogram, SBE
124
Do you receive a TB skin test anymore after testing positive?
No, they will always be positive.
125
How do we describe lung sounds?
What sound it is, where in the respiration cycle it is, location, absence.
126
How do we document abnormal cardiac sounds?
What the sound is, what valvular area you hear it the louder. S1 or S2 present.
127
What are gallops?
Extra heart sounds; fluid volume overload
128
What is a murmur?
Whooshing noise. Caused by valve stenosis or regurgitation.
129
What medications can be used to reduce fluid build up in heart failure?
Diuretics
130
What can happen to the PMI during heart failure?
It can be displaced due to enlargement
131
What is the problem with CVI?
Blood can’t get back to the heart
132
What is the problem with PAD?
Blood can’t get to the extremities.
133
Most serious procedure as a result of PAD?
Amputation.
134
What is the emergency with PAD?
Acute arterial occlusion.
135
What is the emergency with CVI?
DVT
136
How do we diagnose DVT?
Ultrasound.
