Upgrade to remove ads
Assessment - Exam 2
Terms in this set (112)
calculating pack years
packs per day X years smoked
adult pulse rate
adolescent pulse rate
school age child heart rate.
preschooler pulse rate
toddler heart rate
infant heart rate
Newborn respiratory rate
Infant (6 months) respiratory rate
Toddler (2 years) respiratory rate
child respiratory rate
adolescent respiratory rate
adult respiratory rate
average optimal BP for 1 month
average optimal BP for 1 year old
average optimal BP for 6 year old
average optimal BP for 10-13 year old
average optimal BP for 14-17 year old
average adult blood pressure
If you use a BP cuff that is too wide, the BP reading will be a:
False low reading
In colds, viral infections or bronchitis, sputum color will be:
In bacterial infections, sputum color will be:
Patient's with smoke or coal dust inhalation will have a sputum color of:
Patient's with TB or pneumonia will have a sputum color of:
pink, frothy sputum with dyspnea is associated with:
thick sputum is commonly associated with:
foul smelling sputum is typically associated with:
pneumonia, lung abscess, bronchiectasis
increased sputum in the morning and accumulation during the night is common with:
sputum production with a change in position suggests:
lung abscess, bronchiectasis
using a BP cuff too narrow or too short will produce a:
false high reading
using a BP cuff wrapped too loosely or unevenly will produce a:
false high reading
deflating a BP cuff too slowly will result in a _________ reading
false high diastolic
destruction of the alveolar walls causes permanent abnormal enlargement of the airspaces in which condition?
a normal pulmonary assessment consists of assessing:
breathing effort, respiratory patterns, chest expansion, shape
when a COPD/emphysema patient is short of breath, __________ and the_________ will be observed
pursed lip breathing, tripod postion
patient's with advanced emphysema will present as underweight, with a _____________ and becomes dyspenic with minimal exertion.
lung sounds in those with COPD/emphysema
inflammtion of the terminal bronchioles and alveoli
VIRAL PNEUMONIA will present with a ____________ cough or sputum that is _________.
BACTERIAL PNEUMONIA will present with a __________ cough that may produce ________, _______ or _______ sputum.
productive, white, yellow, green
Air in the pleural space is called:
The 3 types of pneumonthorax are:
closed, open, tension
inflammation of the mucous membranes of the bronchiol tree
severe pneumonthroax may displace the _______ toward the unaffected side with a mediastinal shift; also termed a _______ _______.
trachea, tension pneumothorax
In a pneumothorax, breath sounds will be _________ over the affected area.
In a pneumothorax, chest wall movement may be _______ on the affected side
In acute bronchitis, ______ are heard on auscultation, with _______ heard after coughing.
In acute bronchitis, sputum color is:
In acute bronchitis, a cough starts as __________ and becomes _______ within a few days.
fine high pitched crackling & popping noises during inspiration & sometimes on expiration
adventitious breath sound commonly heard in pneumonia, heart failure & restrictive pulmonary diseases
high pitched, musical sound, most commonly heard in expiration but can be heard on inspiration; small airways
adventitious breath sound commonly heard in those with asthma
low pitched, coarse, loud, low, snoring or moaning tone, heard on expiration most commonly.
adventitious breath sound commonly heard in those with COPD, bronchitis and obstruction of the trachea or bronchus
superficial, low pitched, rubbing or grating sound, heard on inspiration and expiration and is not easily cleared by cough
pleural friction rub
adventitious breath sounds commonly heard in those with pleurisy and pericarditis
pleural friction rub
breath sound heard over the main bronchi
breath sounds heard over the lesser bronchi, lobes and bronchioles
breath sounds heard over the trachea
An accumulation of serous fluid in the pleural space between the visceral and parietal pleurae
A hyperactive airway disease characterized by bronchoconstriction, airway obstruction and inflammation
destruction of the alveolar walls causing permanent enlargement of the air spaces
a disorder characterized by hypersecretion of mucus by the goblet cells of the trachea and bronchi, resulting in a productive cough for 3 months in each of 2 successive years
blood in the pleural space caused by chest injury
collapsed alveoli caused by external pressure from a tumor, fluid or air in the pleural space or by lack of air from hypoventilation or obstruction by secretions
an uncontrolled growth of anaplastic cells in one or both lungs
Name the Ausculatory landmarks
aortic, pulmonic, Erb's point, tricuspid, mitral
2nd right intercostal space landmark
2nd left intercostal space landmark
area where aortic and pulmonic sounds radiate
3rd left intercostal space
4th left intercostal space
5th left midclavicular line
A murmur heard after S1 and before S2 is classified as:
a murmur indicative of heart disease and heard after S2 and before S1
murmur: barley audible in a quiet room; usually cardiologists are who hear these
Grade 1 murmur
Murmur: quiet, but clearly audible
Grade 2 murmur
a moderately loud murmur
Grade 3 murmur
a murmur loud and associated with a thrill
Grade 4 murmur
a murmur that is very loud and a thrill that is easily palpable
Grade 5 murmur
a murmur that is very loud and thrill is palpable and visible
Grade 6 murmur
inflammation of parietal and visceral layers of pericardium and outer myocardium
__________ is best heard with patient leaning forward so that the heart is closer to the chest wall
pleural friction rub
In __________ insufficiency, the skin will be hairless, dry, shiny, cool or cool, pallor on elevation and rubor on dangling.
In _______ insufficiency, the skin will be warm, thickened, mottled and be pigmented in areas
In ___________ insufficiency, pain will be sharp and stabbing and worsens with activity and walking, lowering feet may provide some relief
In __________ insufficiency, pain is aching, cramping and heavy; elevating feet relieve pain
In ________ insufficiency, ulcers are painful, pale, with a gray base; found on the heel, toes and dorsum of foot.
In _________ insufficiency, ulcers are moderately painful with a pink base; found on the medial aspect of the ankle
In __________ insuffiency, pulses are absent or diminished
In _________ insufficiency, pulses are usually present.
In __________ insufficiency, edema is infrequent.
In ________ insufficiency, edema is frequent, especially at the end of the day and in areas of ulceration
Name all of the palpation location of pulse sites
carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial, apical
When using light palpation, palpate ____ cm to assess skin, pulsations and tenderness.
When using deep palpation, palpate ___ cm to determine size and contour of an organ
_________ palpation uses both hands, one anterior and one posterior to entrap an organ
_______ percussion is the striking of a finger or hand directly against the body
________ percussion, uses both hands and strikes hand over body location
_________ is used to view size, borders of internal organs and to detect tenderness
Name the percussion tones
tympany, resonance, hyperresonance, dullness, flatness
Which percussion tone is performed over the abdomen?
Which percussion tone is performed on a healthy lung?
Which percussion tone is performed on an inflated lung?
Which percussion tone is performed over the liver?
Which percussion tone is performed over bone?
Loss of consciousness may be caused by ____________ or ____________ disorders
patients are able to demonstrate immediate recall by repeating a series of numbers in the order they're present or in reversed order.
When the nurse states 3 unrelated objects, asks the patient to repeat those objects, then asks the patient, at a later time, to recall the 3 objects again.... What is this testing?
The nurse asks the patient to recall their mother's maiden name, a birthday, or special date in history. What is the nurse assessing?
Recently and immediately impaired; forgetful; unable to recall or follow directions
YOU MIGHT ALSO LIKE...
CP 1: PE, cardiopulmonary, Ophthalm & Otic Exam
fundamentals test 2 lpn
UNF Mod 6 HA
2160 Exam #2 Ch. 14
OTHER SETS BY THIS CREATOR
Professional Nursing Concepts 1- exam 1
Pharmacology - Exam 2
Assessment - Exam 2
Health Care Participant - Exam 2