thorax assessment
heart assessment
arterial vs venous insufficency
miscellaneous
100

name the correct measurements and documentation for:

respiratory rate

type of breath pattern

breath effort

12-20

regular or irregular

labored or unlabored

100

what are the measurements for HR?

60-100

100


Which of the following skin changes is most commonly observed in patients with venous insufficiency?
Yellowing of the skin
Brown pigmentation
Redness and warmth
Pallor and coolness





Brown pigmentation
100

Identify the correct equipment needed for assessment thorax and lungs, heart/peripheral vascular system.

Stethoscope for lungs, doppler and blood pressure for heart

200

what are types of breath sounds?

crackles, wheezes, rails, clear, diminshed

200

S1 and S2 sound like:


lub and dub


200


What is a typical response of patients with arterial insufficiency when their legs are raised?


Increased warmth in the extremities
Pain or discomfort in the affected limb
Improved circulation and reduced symptoms
Numbness and tingling in the toes



Pain or discomfort in the affected limb
200

Identify the correct order of the component parts of physical assessment (inspection, auscultation, palpation, percussion)?

1. Inspection 

2. Palpation

3. Percussion-not for heart

4. Auscultation



300

what is the O2 sat rate 

95-100

300


Which of the following skin findings is most indicative of impaired peripheral circulation?

Warm skin temperature
Pale or cyanotic skin color
Presence of hair growth
Normal skin elasticity





Pale or cyanotic skin color
300

arterial insufficency symptoms

- Diminished or absent pulses

- Pale, cool extremities, dusky red when lowered

- Delayed capillary refill

- Pain with elevation

- Numbness, tingling

300

Describe correct Instructions That the patient should receive prior to assessment of: (a) thorax and lungs and (b) heart/peripheral vascular system.

 - Remain still and breathe normally

- Loosen any tight clothing around the chest area

- Follow instructions for deep breathing or coughing if requested

- Inform the nurse of any pain, tingling or other discomfort during the exam

400

Where would you hear rails? When would you hear wheezes?

in the lower part of the lungs and during inspiration

400


An 86-year-old patient asks why her ankles have a brownish discoloration and the skin looks thick. Which response best addresses the patient's concern?

The valves in the vessels in your legs aren't working as well as they used to, which causes the discoloration and thickening of your skin.

You probably aren't getting enough iron in your diet. We should talk to your doctor about adding an iron supplement.

How many years have you smoked? Nicotine will cause these changes in your skin.

These are just normal changes seen in most older people.





The valves in the vessels in your legs aren't working as well as they used to, which causes the discoloration and thickening of your skin.
400

venous insufficiency symptoms

- Edema in dependent areas

- Distended veins

- Skin discoloration (brown, cyanosis)

- Heaviness in extremities

- Ulcer formation

400

Apply principles of safety, infection control, and privacy during the assessment.

Take pauses when breathing so the patient dont get dizzy, wear a loose shirt, hand hygiene

500

true or false?

The use of acessory muscles is good.

false

500

we are going to pass this exam?

YES

500

Arterial insufficiency is due to

venous insufficiency results from

obstructed arterial blood flow

 impaired venous return and pooling of blood

500

factors that can affect the thorax and vascular system

enviornmental, social, meds, family history, culture, lifestyle, gender, age, pregnancy

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