Ears
This type of hearing loss is caused by presbycusis or by ototoxic drugs.
Normal anteroposterior to transverse diameter ratio for adults.
Normal adult 1:2 to 5:7
1:1 barrel chest
Urticaria (hives) has this type of shape/configuration.
Confluent: lesions merge so that discrete lesions are not visible or palpable.
1) Where do you hear S1 louder than S2 in the heart?
2) Where do you hear S2 louder than S1 in the heart?
1) S1 is louder than S2 at the apex of the heart.
2) S2 is louder than S1 at the base of the heart.
SBP range and DBP range for Prehypertension.
SBP: 120-139 mm Hg
DBP: 80 - 89 mm Hg
How would you assess for this cranial nerve?
CN VIII: Vestibulocochlear
Whispered voice test
List the breath sounds you will hear during auscultation of a normal lung.
1) Bronchial
2) Bronchialvesicular
3) Vesicular
1) Preauricular
2) Postauricular
3) Occipital
4) Submental
5) Submandibular
6) Jugulodigastric
7) Superficial cervical
8) Deep cervical
9) Posterior cervical
10) Supraclavicular
List all the heart sounds you will auscultate.
1) Aortic
2) Pulmonic
3) Erb's point
4) Tricuspid
5) Mitral (apical pulse)
What is Tachypnea?
Involves the mechanical dysfunction of the external or middle ear.
Conductive hearing loss.
1. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.
a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers one, two, three in a very soft voice.
b. As the patient repeatedly says ninety-nine, the examiner clearly hears the words ninety-nine.
c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.
d. As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee sound.
e.As the patient says a long ee-ee-ee sound, the examiner hears a long aaaaaa sound.
A, C, D.
Left Lower Quadrant
True or False?
Jugular veins are distended when a patient is sitting upright.
False.
Jugular veins are normally distended when the patient is supine (laying flat). It is not visible when they are sitting upright.
What pulse qualities are assessed?
The pulse is assessed for rate, rhythm and force.
Inflammation of the 3 semicircular canals (aka labryinth) causes this.
Vertigo.
List the types of adventitious sounds you can auscultate in an abnormal lung.
1) Fine crackles (rales)
2) Course crackles (rales)
3) Sonorous wheezing
4) Sibilant wheezing
5) Pleural friction rub
Which cranial nerves do you use the 6 cardinal fields of gaze for?
Cranial nerves 3 (oculomotor), 4 (trochlear) & 6 (abducens).
18. During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
a. Third left intercostal space at the midclavicular line
b. Fourth left intercostal space at the sternal border
c. Fourth left intercostal space at the anterior axillary line
d. Fifth left intercostal space at the midclavicular line
D. Fifth left intercostal space at the midclavicular line
35. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?
a. These readings are a normal response and attributable to changes in the patients position.
b. The change in blood pressure readings is called orthostatic hypotension.
c. The blood pressure reading in the lying position is within normal limits.
d. The change in blood pressure readings is considered within normal limits for the patients age.
B. The change in blood pressure readings is called orthostatic hypotension.
Orthostatic hypotension is a drop in systolic pressure of more than 20 mm Hg, which occurs with a quick change to a standing position. Aging people have the greatest risk of this problem.
List the two types of Tuning Fork Tests and describe what the normal findings and abnormal findings are.
1) Weber test: ring the tuning fork on top of the patient's head.
Normal finding --> sound is equally heard in both ears.
Abnormal finding --> sound lateralizes in one ear.
- Conductive hearing loss: sound lateralizes to the affected ear.
-Sensorineural hearing loss: sound lateralizes to the better ear.
2) Rinne test: ring the tuning fork perpendicular to the patient's ear and touch the tuning fork end against the mastoid.
- Normal finding --> AC > BC
-Abnormal finding:
Conductive hearing loss: AC < BC in the affected ear.
Sensorineural AC > BC = normal.
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:
a. Normally auscultated over the trachea.
b. Bronchial breath sounds and normal in that location.
c. Vesicular breath sounds and normal in that location.
d. Bronchovesicular breath sounds and normal in that location.
c. Vesicular breath sounds and normal in that location.
List the general sequence when assessing the abdomen.
1) Inspect the abdomen, start at the RLQ and go clockwise.
2) Auscultate for bowel sounds, start at the RLQ and go clockwise.
*If bowel sounds are not present, listen for a full 5 min.
3) Auscultate all vascular sounds (aortic, renal, illiac and femoral arteries).
4) Percuss lightly in all 4 quadrants starting at the RLQ and go clockwise.
5) Palpate surface & deep areas in all 4 quadrants starting at the RLQ and go clockwise.
Describe the general sequence of a heart assessment.
1) Palpate the carotid artery.
2) Auscultate the carotid artery.
3) Inspect the jugular venous pulse.
4) Inspect anterior chest.
5) Palpate the apical pulse.
6) Palpate across the Precordium (thorax region immediately in front of the heart).
7) Ausculate all heart sounds (APETM).
8) Change position to patient from supine to their left side. Auscultate with the bell at the apex of the heart to listen for presence of diastolic filling sounds.
33. When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patients blood pressure?
a. 200/92
b. 200/100
c. 100/200/92
d. 200/100/92
A. 200/92 mm Hg