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FINAL Flashcards

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1
Q

what are the different types of lung sounds (3)

A
  1. broncial
  2. bronchialvesicular
  3. vesicular
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2
Q

characteristics of bronchial breath sounds

A

harsh, high pitched, loud

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3
Q

what is an abnormal breath sound

A

adventitious

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4
Q

characteristics of bronchialvesicular sounds

A

blowing, moderate intensity, moderate pitch

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5
Q

which patient has a barrel chest

A

emphysema

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6
Q

what is a more horizontal position of the ribs, costal angle of more than 90*

A

barrel chest

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7
Q

positive sign of the romberg test

A

moving feet apart

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8
Q

characteristics of the soft palate

A

pink, smooth, moist

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9
Q

CN that assesses the gag reflex

A

CN IX and X

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10
Q

4 things to look for when assessing mental status

A
  1. memory
  2. speech
  3. reasoning
  4. judgement
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11
Q

where to percuss the triceps reflex

A

above the olecranon process

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12
Q

suggestive of breast malignancy

A

retraction of the breast

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13
Q

CN that is tested by clenching teeth

A

trigeminal nerve

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14
Q

type of assessment that is performed for a particular problem

A

focused

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15
Q

when should a clinical breast exam be done

A

every 3 years for young adult women

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16
Q

dysfunction of CN VIII

A

vertigo

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17
Q

when objects look blurry up close

A

presbyopia

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18
Q

sound that is heard when auscultating the heart in CHF pt’s

A

S3

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19
Q

slow, less than normal

A

brady

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20
Q

characteristics of vesciular breath sounds

A

sighing, low pitch, soft intensity

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21
Q

4 adventitious lung sounds

A
  1. crackles (rales)
  2. ronchi (gurgles)
  3. friction rub
  4. wheeze
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22
Q

organ that is in the ULQ

A

spleen

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23
Q

where the mitral/apical pulse is located

A

5th ICS, MCL

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24
Q

tests for low back pain

A

straight leg test

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25
what does documentation promote
communication between team members
26
when to use a Doppler
if there is a non-palpable pulse where there was not an absent pulse before **change**
27
where the apex/apices of the lungs located
slightly above the clavicles
28
orthopnea
difficulty breathing when lying supine | *indicative of CHF
29
tripod position is assoc. with
seen in pt's with COPD
30
CN for smell
CN I (olfactory)
31
clear watery drainage from the ear
CSF
32
race and gender that has a higher risk for heart failure
African American male
33
when do you palpate the abdomen
last
34
infection of the ear that causes a tender tragus
otitis externa
35
pulse that is used to assess for arrhythmias
apical
36
foundation of the nursing process
assessment
37
when kyphosis is normal
in older adult pt's * hunchback * overexaggerated curve in the posterior aspect of the spine
38
dimpling or retraction of the breast is usually caused by f
malignant tumor
39
pig-skin like or orange-peel appearance results from edema is seen in
metastatic breast disease
40
Peau d'orange results from
edema | metastatic breast disease
41
tingling, itching, increased sensitivity, burning, discharge, and pain in the nipple are late signs of
Paget's disease
42
where to assess pallor in a dark skinned client
buccal mucosa
43
vagus nerve dysfunction
drooling
44
when an older pt c/o weakness and fatigue, 1st thing RN should do
RULE OUT ANEMIA
45
infection that can cause absent bowel sounds
peritonitis
46
ask client to __ when auscultating their thyriod
hold breath
47
used to measure angles
goniometer
48
used to maintain privacy and confidentiality of pt's
HIPPA
49
characteristics of resonance
when percussing loud low pitched hollow sounds
50
5 sounds elicited from percussion of lungs and location
1. flatness (muscle/bone) 2. dullness (dense tissues) 3. resonance (lungs filled with air) 4. hyperresonance (assoc. c. emphysema pt's) 5. tympany (air-filled stomach)
51
priority of carotid assessment
auscultation
52
characteristics of cluster headache
pain to the eye and temple
53
how to percuss the sinuses
percuss
54
characteristics of arterial insufficiency
deep, cervical, painful ulver
55
consensual response (2)
indirect response | other pupil constricts when light is shone into eye
56
part of the brain that controls balance and coordination
cerebellum
57
describe petechiae
small, flat, reddish, purple macules
58
if a pt has a score of 7 on the GCS, this pt is __
in a coma
59
if a pt has a score of 14 on the GCS, this pt is __
WNL
60
method of interview process that is exploring and investigating symptoms
***
61
Dr. gives an order over the phone. what should you do before you disconnect the call?
read back the order
62
internally rotating the lower extremities
decorticate
63
__ can cause pinpoint pupils
narcotics
64
visual disturbance in the prodromal stage
migraine
65
most common pulse site
radial
66
where is referred rebound tenderness located
LLQ
67
what test requires the use of a tuning fork to the mastoid process
Rinne
68
test to assess knee swelling
bulge test
69
if a pt has a hip fx, what will they complain of
thigh pain
70
normal degree of lumbar and thoracic extension
30*
71
describe macule
flat, non-palpable lesions
72
organ that causes RUQ and shoulder pain
gallbladder
73
what do you assess for when using bronchophony
use phrase "ninety-nine"
74
what do you assess for when using whispered pectiloroquy
use phrase "1-2-3"
75
sibilant wheezes are heard in what types of pt's
acute asthma | chronic emphysema
76
fine crackles are heard in what types of pt's
PNA | CHF
77
coarse crackles are heard in what types of pt's
PNA PE pulmonary fibrosis
78
sonorous wheezes are heard in what types of pt's
bronchitis single obstructions snoring before an episode of sleep apnea
79
what race has a larger thorax and greater lung capacity
Caucasians
80
decreased respiratory rate, decreased depth, irregular pattern
hypoventilation
81
regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea
Cheyene-Stokes respiration
82
irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea
Biot's respirations
83
rapid, deep, labored breathing
Kussmaul
84
pectus carinatum AKA...
pigeon chest

Health Assessment (2 decks)

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