NUR 216 Exam 3

What sound occurs when the aortic and pulmonic valves close at the beginning of diastole?

"Dub" or S2 -Heard best at the base of the heart and the aortic and pulmonic listening posts

What heart sound occurs when the tricuspid and mitral valves snap shit at the beginning of systole?

"Lub" or S1 -Loudest at the apex of the heart over the tricuspid and mitral valves

How many lobes does the right lung have?

3 lobes

Pulmonic is best used for?

Best used for hearing the pulmonic value

Nails during inspection

Check for clubbing

What is COPD?

Chronic bronchitis/emphysema -Loss of lung elasticity -Air gets trapped in lungs and do not deflate (hyperinflation) -Alveoli get damaged resulting in decreased surface area for gas exchange -CO2 retention and respiratory acidosis

What does COCA stand for?

Color, Odor, Consistency, Amount

If your patient presents with severe epistaxis, what is important for you to check quickly? A. Their history B. Their height C. Their weight D. Their vital signs

D. Their vital signs

What is a Grade 3 murmur?

Moderately loud

What is bradypnea? What are the causes?

Slow breathing -opioids and sedatives

What is respiration?

The mechanical process of inhalation

What is the Snellen chart used for?

Vision test

What does SOB stand for?

shortness of breath

What is a ventricle?

thick-walled, muscular pumping chamber

What is an atrium?

thin-walled reservoir for holding blood

What is a Grade 6 murmur?

very loud, may be audible without touching the clients chest, associated with palpable and visible thrill

Neck Vessels: Palpation

•Using your index and middle finger, palpate the carotid arteries in the groove between the sternocleidomastoid muscle & throat •Assess the carotid pulse for its strength •Palpate each carotid artery individually •Expected findings: -Strength is moderate & equal bilaterally ▪Expected variations: Use extra caution in older adults. Underlying medical conditions can make them more likely to experience syncope during palpation of the carotid arteries. (Carotid massage) ▪Unexpected findings: -Very strong pulse or bounding pulse à fluid overload d/t HF -Diminished or weak pulse à blockage, stenosis of the artery, very low circulating blood volume (ex. shock)

How many chambers are in the heart? What is their main purpose?

-4 chambers in the heart -Main purpose is to prevent backflow of blood -Valves are unidirectional: can only open one way -Valves open and close passively in response to pressure gradients in moving blood

What is right sided heart failure?

-Blood goes back into the extremities -fatigue -ascites (fluid build up) -JVD -Anorexia/GI tract distress -Weight gain (1-2 lbs. per day) -Dependent Edema

What is left sided heart failure?

-Blood goes back into the lungs -Paroxysmal nocturnal dyspnea -Pulmonary congestion -tripod position -tachycardia -fatigue -cyanosis -confusion -exertional dyspnea

Assessment findings for COPD include

-Chronic productive cough -SOB -Tachy -fatigue -Clubbing -increased AP diameter

Percussion Assessment

-Compare sounds from side to side -Percussion of the thorax elicits resonance -Expected finding: Resonance-low pitched, clear, and hollow sound in healthy lung tissue -Unexpected: Hyperresonance- Lower pitched booming sound (ex: too much air such as emphysema or pneumothorax) Dullness- soft muffled thud (ex: density in lungs such as pneumonia or tumor)

Late symptoms of hypoxia

-Decreased LOC (stupor) -Bradycardia -Dysrhythmias -Bradypnea -Decrease BP -Cyanosis

What are the expected respiratory changes in older adults?

-Decreased surface area -Decreased breathing and lung capacity -Increased dead space -Decrease vital capacity (AP diameter becomes similar to transverse diameter) -Cilia become ineffective at removing dust and irritants which leads to a decreased cough reflux -Tire more easily during auscultation

Auscultation Assessment

-Evaluate presence and quality of normal breath sounds -Instruct patient to breath through mouth, a little bit deeper than normal -Use diaphragm of stethoscope and hold it firmly on person's chest wall; listen to at least one full respiration in each location -Auscultate under the gown/clothes -do not confuse background noise with lung sounds

Breathing rate and pattern during inspection includes

-Expected finding: Resp quiet, with regular rhythm and depth -Unexpected finding: Tachypnea, bradypnea, Cheyne-stokes, dyspnea, orthopnea, Kussmaul's breathing (ataxic breathing)

Depth of breathing during inspection include

-Expected finding: Unlabored quiet breathing -Unexpected finding: Shallow and deep

Skin color during inspection

-Expected finding: skin color appropriate for ethnicity -Unexpected: Cyanosis or pallor

What are the risk factors of Asthma?

-Family history -smoking -second hand smoke -environmental allergies -GERD

Anterior Chest: Inspection

-Inspect the anterior chest for symmetry of chest movements and visible pulsations -observe the area over the apical pulse or PMI at the apex of the heart for visible pulsations -Expected findings: Symmetrical chest movements, visible and gentle pulsations in the PMI area -Unexpected findings: Lift (or heave); prominent, forceful thrusting in the PMI area (ex: HF)

Neck Vessels: Inspection

-Note jugular veins and carotid arteries -HOB at 35-45 degrees -Expected findings: No jugular neck vein distention, carotid area with visible pulsations -Unexpected findings: Full, bulging, and bounding jugulars on one or both sides of the neck (this occurs in right sides heart failure) Absence of pulsation in the carotid artery leads to decrease in the force of blood flow

What are the layers of the heart wall? What do they do?

-Pericardium: tough fibrous, double-walled sac that surrounds and protects the heart -Myocardium: muscular wall of the heart; it does the pumping -Endocardium: thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

Expected cardiovascular changes in older adults?

-Postural hypotension -Systolic HTN -Cardiac output decreases and strength of contractions leads to poor activity tolerance

What is a nurse looking for during a respiratory assessment?

-Respiratory rate -Respiratory effort -Respiratory depth -LOC -Color -Muscle use -Adventitious sounds? -Diaphoretic -Is the client's position tripod?

What are the components of a cardiovascular exam?

-Review vital signs (normal BP?, Prehypertension? Stage 1 or 2 HTN) -Look for finding of cardiovascular problems -Inspect and palpate the neck for carotid pulses -Auscultate the neck for bruits - Inspect and palpate the precordium for pulsations -Auscultate over the precordium at 5 auscultatory sites

How many valves does the heart have? What are they?

-Two atrioventricular (AV) valves: tricuspid and mitral valve -Two semilunar (SL) valves: pulmonic and aortic valve

Neck Vessels: Auscultation

-Using the bell and light pressure, listen over the carotid arteries for bruits -(blowing or swishing sounds that reflect turbulent blood flow) -Might have to listen to 2 or 3 places along the carotid artery -Ask the client to hold their breath briefly if you are unable to auscultate with them breathing

What is asthma?

-chronic inflammatory disorder of the airways -Intermittent airflow obstruction:bronchoconstriction

Interventions for COPD include

-high fowlers - breathing exercises and taking medications

Palpation Assessment

-tenderness, lesions, lumps, deformities -assess chest excursion or expansion of the posterior thorax -assess for vocal (tactile) fremitus

What is the scale for palpating arteries?

0: Absent, nonpalpable +1: Diminished, barely palpable, or weak and thready +2: Normal pulse, easy to palpate +3: Full and easy to palpate +4: Bounding, very strong

What are the pitting edema grades?

1+ edema: 2mm indentation 2+ edema: 4mm indentation 3+ edema: 6mm indentation 4+ edema: 8mm indentation

What is the blood flow order through the heart?

1. Vena cava 2. Right atrium 3. Tricuspid valve 4. Right ventricle 5. Pulmonic valve 6. Pulmonic arteries 7. Pulmonic veins 8. Left atrium 9. Mitral valve 10. Left ventricle 11. Aortic valve 12. Aorta

How many auscultation points are on the posterior thorax?

10 on the back

How many auscultation points are on the anterior thorax?

10 on the front 2 on the sides

How many lobes does the left lung have?

2 lobes

What is the expected heart rate range?

60-100 beats/min

What is the expected range for oxygen saturation?

95-100%

What is scoliosis?

A deformity caused by a lateral curvature of the thoracic spine. It is typically detected in adolescence. Mild scoliosis usually has little consequence, but more severe curvature can restrict lung function.

If you are unable to find a pulse what tool can you use?

A doppler

What is a tympany sound?

A loud, high-pitched, drum-like sound elicited by percussion. Heard over the abdomen, it can indicate gastric or intestinal air or air bubbles.

The nurse knows that the proper technique for assessing lungs in an adult patient is that auscultation is performed: A. By auscultating side to side from one lung to the other B. From top to bottom of the right lung then auscultating from top to bottom of the left lung C. Using only the bell of the stethoscope D. By auscultating the anterior and posterior of the right lung first before auscultating the anterior and posterior of the left lung

A. By auscultating side to side from one lung to the other

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the clients breathing. The nurse should identify this observation as which of the following findings? A. Crackles B. Stridor C. Wheezes D. Friction Rub

A. Crackles Rationale- crackles, sometimes called rales, are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration of breathing.

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include? A. Insert the earpieces at a downward angle towards your nose B. Use the diaphragm to listen to low-pitched sounds. C. Drape the stethoscope over your neck when not in use. D. Clean the stethoscope by immersing it in soapy water.

A. Insert the earpieces at a downward angle towards your nose Rationale-The nurse should insert the earpieces at a downward angle toward their nose because this helps ensure that sounds are effectively transmitted to their eardrums.

Which of the following indicate cranial nerve XII is intact? A. The client can stick out their tongue B. The client can smile symmetrically C. The client can hear whispered words D. The client can identify a mint scent

A. The client can stick out their tongue -Cranial nerve XII, the hypoglossal nerve, controls the strength and mobility of the tongue. To test this nerve's function, the nurse should ask the client to stick out their tongue, then move it from side to side.

What should you palpate before inserting the otoscope into the patient's ear? A. Tragus B. Lymph nodes C. Helix D. Earlobe

A. Tragus

What is the pneumonic used for the five auscultatory sites? What do they stand for?

APE To Man Aortic area Pulmonic are Erb's point Tricuspid area Apical/Mitral

What is a pneumothorax?

Accumulation of air or gas in the pleural space causing the lung to collapse

What is borborygmi?

Are hyperactive bowel sounds indicating increased intestinal motility. Common causes are diarrhea, gastroenteritis, bleeding, anxiety, and early bowel obstruction.

What disorders are associated with diminished lung sounds?

Atelectasis, pleural effusion, and pneumonia with consolidation

Aortic is best used for?

Auscultating this site is most useful for assessing the aortic value

Eye discharge is usually associated with: A. Hypertension (HTN) B. Conjunctivitis C. Otitis externa D. Meibomianitis

B. Conjunctivitis

The nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? A. Document accurate data B. Develop a plan of care C. Validate previous data D. Evaluate outcomes of care

B. Develop a plan of care Rationale- The first action the nurse should take using the nursing process is to assess the client and develop a plan of care. The nursing process follow the steps of assessment, analysis, planning, implementation, and evaluation.

Which symptom commonly accompanies throat pain? A. Eye pain B. Ear pain C. Headache D. Nasal congestion

B. Ear pain

Disorders in which parts of the ear usually result in earaches? A. Inner and middle ear B. Inner and external ear C. Middle and external ear D. Travis and eardrum

B. Inner and external ear

A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? A. Auscultation B. Inspection C. Percussion D. Palpation

B. Inspection Rationale- The first action the nurse should take using the nursing process is to assess the client. The nurse should begin a complete physical examination by inspecting the client's body systematically, observing for both expected and unexpected physical findings. When assessing most body systems, the recommended order is inspection, palpation, percussion, and auscultation.

A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? A. Lordosis B. Kyphosis C. Ankylosis D. Scoliosis

B. Kyphosis Rationale- kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older clients who have had vertebral fractures.

A nurse is palpating a tender area of a clients abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the findings should the nurse document? A. Borborygmi B. Rebound Tenderness C. Tympany D. Abdominal Guarding

B. Rebound Tenderness Rationale- The nurse should document that the client is experiencing rebound tenderness, which is an increase in pain when deep palpation over a tender area is released. Rebound tenderness is in the right lower quadrant at McBurney's point (one-third the distance from the anterior iliac crest to the umbilicus) is an indication of acute appendicitis.

Which type of hearing loss results from disorders of the inner ear or of the eighth cranial nerve? A. Conductive hearing loss B. Sensorineural hearing loss C. Mixed hearing loss D. Functional hearing loss

B. Sensorineural hearing loss

Which of the following indicate cranial nerve VII is intact? A. The client can stick out their tongue B. The client can smile symmetrically C. The client can hear whispered words D. The client can identify a mint scent

B. The client can smile symmetrically -Cranial nerve VII, the facial nerve, controls facial expression. To test this nerve's function, the nurse should ask the client to smile, frown, raise their eyebrows, or puff out their cheeks while checking for symmetry.

Tricuspid is best used for?

Best used for listening to the tricuspid value

A nurse is performing a cardiovascular assessment on a client which of the following findings should the nurse expect? A. A continuous sensation of vibration felt over the second and third left intercostal spaces B. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum C. A brief thump felt near the fourth or fifth intercostal space near the left mid clavicular line D. A whooshing or swishing sound over the second intercostal space along the left arsenal border

C. A brief thump felt near the fourth or fifth intercostal space near the left mid clavicular line Rationale- This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulse station, it occurs as the Apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is an expected finding and should be performed when you are preparing to auscultate the apical pulse.

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client's foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses? A. Posterior tibial B. Popliteal C. Dorsalis Pedis D. Femoral

C. Dorsalis Pedis Rationale- To palpate the dorsalis pedis, the nurse should place their fingertips on the top of the client's foot, between the extensor tendons of the great toe and those of the toe next to it. The dorsalis pedis is the most common pulse tested in the lower extremities.

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first? A. Right upper quadrant B. Left upper quadrant C. Right lower quadrant D. Left lower quadrant

C. Right lower quadrant Rationale-Evidence-based practice indicates that the first area the nurse should auscultate for active bowel sounds is over the right lower quadrant of the client's abdomen. The right lower quadrant is located to the right of the umbilicus and contains the ileocecal valve. This is where the small intestine connects to the large intestine, and it is normally very active with bowel sounds. For an average adult, the nurse should expect to hear 5 to 30 bowel sounds per minute.

Which of the following indicate cranial nerve VIII is intact? A. The client can stick out their tongue B. The client can smile symmetrically C. The client can hear whispered words D. The client can identify a mint scent

C. The client can hear whispered words -Cranial nerve VIII, the auditory nerve, controls hearing. To test this nerve's function, the nurse should ask the client to plug one ear, and then whisper a few words into their unplugged ear to assess their ability to hear whispered words.

Risks for having COPD include

COPD exacerbations due to flue, pna, allergies -They do not do we well at overcoming respiratory illnesses

What occurs when a client has abnormally high pressure on the right side of heart?

Client shows signs in neck veins and abdomen

What might you expect in a client when S3 follows S2?

Congestive heart failure

A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics? A. Gait B. Hearing C. Vision D. Balance

D. Balance Rationale- The nurse should explain that the Romberg test is the most common test of balance

A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve 1 is intact? A. The client can stick their tongue out B. The client can smile symmetrically C. The client can hear whispered words D. The client can identify a minty scent

D. The client can identify a minty scent Rationale- Cranial nerve 1, the olfactory nerve, controls the sense of smell. To test this nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as mint or coffee

Which term is used to test for corneal sensitivity? A. Cotton-tipped applicator B. Gauze pad C. Tissue D. Wisp of cotton

D. Wisp of cotton

What is a Grade 1 murmur?

Difficult to hear, even in a quiet room

What is the most common pulse tested in the lower extremities? Where is it found?

Dorsalis pedis pulse -found on the dorsum if the foot between the extensor tendons to the great toe and the toe next to it.

When do SL valves open?

During pumping, or systole, to allow blood to be ejected from the heart

When do AV valves open?

During the hearts filling phase or diastole to allow the ventricles to fill with blood

When do AV valves close?

During the pumping phase, or systole, to prevent regurgitation of blood back into the aorta

What is perfusion?

Exchange of O2 and CO2 between RBCs and body tissues -Hypoxia occurs if there is not enough

What is diffusion?

Exchange of O2 and CO2 between alveoli and RBCs (in blood) -Hypoxemia occurs if there is not enough

What are adventitious sounds?

Extra breath sounds that are abnormal. Crackles, rhonchi, wheezes, and pleural friction rub.

What occurs when a client has abnormally high pressure in the left side of the heart?

Gives the client symptoms of pulmonary congestion

What is abdominal guarding?

Guarding is a voluntary tightening or tensing of muscles when an examiner palpates a tender or painful area.

What is a Weber test used for?

Hearing

What would be an unexpected finding when percussing the thorax?

Hyperresonance-lower pitched booming sound (too much air in the lung tissue) Dullness- soft and muffled thud (density in lungs)

What is associated with S4 immediately proceeding S1?

Hypertension, coronary artery disease, and often myocardial infarction

what is it called if diffusion is inadequate?

Hypoxemia

What is it called if not RBC's aren't bringing enough oxygen to tissues?

Hypoxia

What is ankylosis?

Immobility and consolidation of a joint due to disease, injury, or surgical procedures. The stiff joint is often a result of a congenital condition or scarring.

what health assessment techniques are used in a lung assessment?

Inspection, palpation, percussion, ausculation

What is Biot's breathing? What are the causes?

Irregular breathing or tachypnea with long periods of apnea -caused by brain damage

What is Erb's point used for?

It is a common listening post, lying halfway between the base and the apex of the heart

What should you do if SpO2 is less than 90%?

It is emergent- Take actions and report to MD -SpO2 for those with chronic lung disease such as COPD can be as low as 90s

What is JVD?

Jugular vein distention -found when blood flow refluxes (flows backward) from the right atrium into the jugular veins

What is lordosis?

Lordosis, or swayback, is an abnormal exaggerated lumbar curve (anterior convexity) of the lumbar spine. It is common in clients who are obese or pregnant.

What is a Grade 4 murmur?

Loud and associated with a thrill

What is Cheyne-Stokes breathing?

Near death breathing pattern -Apnea followed by gradual increase in breaths following by apnea -caused by cardiac damage

Where is the PMI expected?

Near the fourth or fifth intercostal space near the left midclavicular line, and covers an area no larger than that of a nickel

Assessory Muscle use during inspection includes

Neck muscles, intercostal muscle retractions, supraclavicular

What is a thrill?

Palpable vibration caused by turbulent blood flow

What is PMI?

Point of Maximal Impulse (apical pulse)

In which area is S1 and S2 typically equal in sound volume?

Pulmonic area

What is tachypnea? What are the causes?

Rapid breathing -anxiety, fear, fever, exercise, illness

What is Kussmal breathing? What are the causes?

Rapid, deep, labored breathing -Shock, septic, and renal failure

what should you assess in your general survey? (pulmonary)

Respiratory rate, respiratory effort, respiratory depth, LOC, color, muscle use, adventitious sounds, diaphoretic, patients position

What is the apical/mitral area used for?

Same site as PMI (point of maximal impulse) at the apex, located in the fifth intercostal space at the left midclavicular line.

What is a pericardial friction rub?

Scratching or squeaking sound heard over the precordium that indicates inflammation of the pericardial lining

What are you looking for during inspection of a respiratory assessment?

Shape of chest wall- -Expected finding: Anteroposterior diameter (AP) is 1/3 to 1/2 less than the transverse diameter. No retraction of use of accessory muscles -Unexpected finding: Barrel chest 1:1 Spinal deformities, kyphosis, scoliosis Position of the client- -Expected: relaxed posture -Unexpected: tripod (ex. COPD) with pursed lips Cough- -Productive or non productive -Note COCA LOC- -Expected: Client should look relaxed and comfortable -Unexpected: Hypoxia can result in restlessness and agitation; the client may appear anxious -Decreased LOC with severe hypoxia

What causes COPD?

Smoking, air pollution, wood smoke, workplace fumes/dust

what tools are used for a respiratory assessment?

Stethoscope, watch, pulse oximeter, spirometer

What are the pulse points? (10)

Superficial temporal External maxillary Carotid Brachial Ulnar Radial Femoral Popliteal Dorsalis pedis Posterior tibial

What is the vital capacity of the lungs?

The amount of air that can be breathed in after a maximum inspiration

What is the pneumonic for the valves?

Tissue, Paper, My, Assets Tricuspid Pulmonic Mitral Aortic

What position does a PT who id having difficulty breathing assume?

Tripod

What is a Grade 5 murmur?

Very loud, easy to palpate thrill

What is rhonchi?

a low-pitched wheeze that may clear with coughing. -Ask the client to take a deep breath and cough a couple of times and then listen again

What is kyphosis?

a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older clients who have had vertebral fractures.

What is a friction rub?

a scratching or squeaking sound that persists throughout the respiratory cycle and does not clear with coughing. It can result from the pleural membranes covering the lungs and the lining of the thoracic cavity becoming inflamed.

What is a Grade 2 murmur?

clearly audible but quiet

What are wheezes?

continuous squeaking sounds that can be high-pitched, which is common in asthma, or low-pitched with an almost snoring quality. Low-pitched wheezes are sometimes called rhonchi. Mild wheezing is often limited to the expiratory phase of respiration, while more severe wheezing can be heard throughout the respiratory cycle.

what is the primary function of the lungs?

exchange of O2 and CO2

Where are bronchial breath sounds heard?

heard anteriorly over the trachea. You should hear a loud, high-pitched, hollow sound. It is abnormal to hear this sound over peripheral lung tissue (away from the trachea and large bronchi)

What are bruits sounds?

heard as blowing or swishing sounds that reflect turbulent blood flow

Where are vesicular sounds heard?

heard over most of the lung tissue. You should hear soft, fine, breezy, low-pitched sounds. These are expected over peripheral lung tissue, which is formed by groups of alveoli and is where air exchange occurs

Where are bronchovesicular sounds heard?

heard over the mainstream bronchi, which are relatively large-diameter airways. You should hear medium-pitched and quieter sounds. The areas over which bronchovesicular sounds are expected are small but present both anteriorly and posteriorly

What is stridor?

is a high-pitched sound typically generated when a larger airway is blocked by a foreign body, severe inflammation, or a mass. -Can be heard without a stethoscope

What is atelectasis?

is an absence of breath sounds in the bases of the lower lobes of the lungs due to collapse alveoli. Cause include hypoventilation, obstruction from secretions if the client is unable to deep breath and cough sufficiently, external tumor, and fluid or air in the pleural space

What is ventilation?

movement of air into and out of the lungs

What sound should be heard when percussing the thorax?

resonance- Low pitched, clean, and hollow sound in healthy lung tissue

early symptoms of hypoxia

restlessness, anxiety, tachycardia/tachypnea, increase BP, Pallor, Abnormal breathing