Show:
inspect
asculate
palpate
percuss
subjective
100
while inspecting an adolescent patient, the nurse notices unequal shoulder distribution and unequal hip level. what is this indicative of?
What is scoliosis
100
a pregnant adult client comes in for a check up with her OBGYN. upon asculating the client, the nurse hears a continous murmur from the breast vasculature, what is this known as?
What is a mammary souffle?
100
The nurse begins to palpate over the lung apices in the subclavicular areas then compares vibrations from one side to the other as the person repeats "ninety nine"
What is tactile fremitus?
100
during percussion a low-pitched,clear, hollow sound that predominates in healthy lung tissue in the adult.
What is resonance?
100
a client reports having a pink, frothy sputum, what is this a characteristic of?
What is pulmonary edema?
200
while Inspecting an older client, the nurse notices an increased AP diameter, barrel chest, accessory muscles used to aid respiration. the client is standing in the tripod position, especially on exertion. the nurse notices the client has had difficulty breathing, and abnormal rapid breathing. what is this an indicator of?
What is emphysema?
200
The nurse was auscultating the infant client and heard discontinuous popping sounds over inspiration
What are crackles sounds
200
This condition is initially asymptomatic, showing a sign of positive skin test. On palpating this patient, skin is moist from night sweats. what is the positive skin test a sign of
What is exposure to tuberculosis?
200
A dull percussion note in the lower left quadrant at the anterior axillary line bellow the tenth rib at the mid axillary line.
What is splenic enlargement
200
Patient comes into the emergency complaining " i can't breathe, i can't breathe" and my chest hurts too, and is worse when i breathe in
What is acute respiratory distress?
300
while standing on the adult clients right side, the nurse notices a throbbing pulse, what does this indicate and what is the cause?
What is full distended external jugular vein; associated with right sided heart failure
300
Upon auscultating the adolescent patient, the nurse hears continuous musical sounds when the client exhales.
What are wheezes
300
A client comes in with signs of increased pressure, pulmonary congestion. the client has moist, clammy skin. the nurse palpates for tactile fremitus and the results come back normal. what is this a sign of?
What is heart failure
300
while listening to the lungs of a patient, this sound is heard over most portions.
what is tympany?
300
Patient complains of short of breath after walking one block. chest tightness, early morning cough daily with small amount of white sputum for the past 3 years. She also complains of waking up at in the nights 2-3 times to urinate or catch breath. She also states thinking of quitting smoking but previous attempts have not work.
What is chronic obstructive pulmonary disease?
400
while inspecting an older patient the nurse notice swelling associated with pain,heat, redness and pitting of 3+. what is this a sign of?
What are the signs of edema?
400
it can be heard in any place within the pericardium but usually is best heard at the apex and left lower sternum border, places where the pericardium comes in close contact with the chest wall.
What is pericardial friction rub?
400
for the infant client, the nurse palpates what impulse to determine the size and position of the heart?
What is the apical impulse
400
Resonance sounds are above normal, and lower pitch on percussion of the chest as a result of over inflation of the lung as in emphysema. What type of resonant sound is this?
What is hyperresonant
400
a client is seen by the nurse and reports waking up frequently through out the night due to shortness of breath. she states that the only comfortable position for her to sleep in at night is upright. the client states she uses 3 pillows and this helps her breath better. what are these signs indicative of?
What is Orthopnea and Paroxysmal nocturnal dyspnea
500
Weight loss, clubbing, hoarseness, anemia, and hemoptysis
What are signs and symptoms of lung cancer?
500
while auscultating the adult clients carotid artery, the nurse notices a blowing, swishing sound which indicates what?
What is bruit
500
While the nurse is palpating the client, she notices the throat almost feels like the throat of a "purring cat", a swishing sound and loud murmurs. what is this a sign of?
What is a thrill
500
It is easier to percuss the spleen in a patient in the ______ position
What is decubitus position?
500
a client comes in and reports radiating pain to the jaw, neck and shoulder. He states that pressure on his chest when sitting and watching TV and first thing in the morning, what is this an indicator of?
What is variant angina aka prinzmetal