Show:
Head and Neck
Eyes/Ears
Thorax and Lungs
Cardiovascular
Peripheral Vascular
100
What is a bruit?
Abnormal sound heard in blood vessels. Indicates turbulent blood flow (atherosclerosis).
100
The normal color of the optic disc is: A) red. B) creamy pink. C) creamy yellow-orange to pink. D) creamy red to yellow-orange.
C
100
Name some adventitious breath sounds.
Crackling, wheezing, rhonchi, stridor, diminished, etc.
100
Define preload and afterload.
Preload, also known as the left ventricular end-diastolic pressure (LVEDP), is the amount of ventricular stretch at the end of diastole. Think of it as the heart loading up for the next big squeeze of the ventricles during systole. Afterload, also known as the systemic vascular resistance (SVR), is the amount of resistance the heart must overcome to open the aortic valve and push the blood volume out into the systemic circulation
100
Describe 3 mechanisms that help return blood to the heart.
1. contracting skeletal muscles that milk the blood proximally, back to the heart. 2. pressure gradient caused by breathing. Inspiration causes increased thoracic pressure and increased abdominal pressure. 3. Intraluminal valves
200
What is JVD and what can cause it?
Jugular vein distention. This occurs when all the blood cannot return to the right side of the heart. This can be caused by R sided HF, infection of the heart lining, cardiac tamponade, or anything that restricts the volume of the heart.
200
Which of the following is an expected response on the cover test? A) The covered eye moves into a relaxed position. B) The covered eye maintains its position when uncovered. C) The uncovered eye is unable to maintain its gaze on a fixed object. D) The covered eye jumps to reestablish fixation when it is uncovered.
B Rationale: A normal response to the cover test is a steady fixed gaze. If muscle weakness is present, the covered eye will drift into a relaxed position. A normal response to the cover test is a steady fixed gaze. When the eye is uncovered, if it jumps to reestablish fixation, eye muscle weakness exists.
200
Describe the most important points about the health history for the respiratory system.
1. Cough? 2. Short of breath? 3. Chest pain while breathing? 4. History of respiratory infections? 5. Smoking history? 6. Environmental exposure?
200
Explain what causes normal S1 and S2 sounds.
S1 is the sound of the closing of the mitral and tricuspid valves. S2 is the sound of the closing of the aortic and pulmonic valves.
200
List some risk factors for venous stasis.
Prolonged standing, sitting, or bed rest; hypercoagulation state; vein wall trauma; incompetent valves; genetics; obesity; multiple pregnancies
300
How does the nurse assess lymph nodes? Are they usually palpable?
The nurse assesses the lymph nodes by moving his/her finger pads over the area using a gentle circular motion. Lymph are not usually palpable.
300
Differentiate among the types of hearing loss and give examples.
Conductive hearing loss: involves a mechanical dysfunction of the external or middle ear and is considered a partial loss because the person is able to hear if the sound amplitude is increased enough to reach the nerve elements in the inner ear. Common causes are impacted cerumen, foreign bodies in the ear canal, perforated TM, and otosclerosis. Sensorineural hearing loss: indicates pathology of the inner ear, cranial nerve VIII, or the auditory areas of the brain. A simple increase in amplitude may not enable the person to hear. Common causes are ototoxic drugs and presbycusis, a gradual nerve degeneration that occurs with aging. Mixed loss: combination of both types of hearing loss in the same ear.
300
What is tripod position?
Leaning forward with arms braced against knees, chair, or bed. Gives leverage so the abdominal, intercostal, and neck muscles all can aid in expiration.
300
Explain where to auscultate the pulmonic, aortic, tricuspid, and mitral valves.
Pulmonic: second left interspace Aortic: second right interspace Tricuspid: left lower sternal border Mitral: fifth interspace, left midclavicular line
300
Compare the characteristics of leg ulcers associated with arterial insufficiency with ulcers with venous insufficiency.
Arterial ulcers are d/t buildup of plaques on intima and hardening/calcification of arterial wall. They usually occur at toes, metatarsal heads, heels, and lateral ankles. The are characterized by pale ischemic base, well-defined edges, no bleeding. Subjective data: deep muscle pain in calf or foot, claudication, pain at rest. Objective data: coolness, pallor, elevational pallor, dependent rubor, diminished pulses, systolic bruits, malnutrition, distal gangrene. Venous ulcers are d/t acute DVT or chronic incompetent valves in deep veins. More common than arterial ulcers. Usually occur at medial malleolus. Characterized by uneven edges and bleeding. Subjective data: aching pain in calf or lower leg, worse at the end of the day or with prolonged standing; itching with stasis dermatitis. Objective data: lower leg edema that does not resolve with diuretics; firm, brawny edema; course thickened skin; normal pulses; brown discoloration; petechiae, dermatitis; irregular borders; shallow and may contain granulation tissue; sometimes weepy, pruritic.
400
The neonate's skull bones are separated by sutures and ____________?
Fontanels
400
Relate the anatomic differences that place the infant at greater risk for middle ear infections.
The infant's Eustachian tube is shorter and wider than an adult's, and its position is more horizontal; therefore, it is easier for pathogens from the nasopharynx to move through the Eustachian tube to the middle ear.
400
During percussion, which sound would you expect to predominate over normal lung tissue?
Low-pitched, clear, hollow sounds.
400
S1 is best heard at the _____ of the heart, whereas S2 is loudest at the _____ of the heart. S1 coincides with the pulse in the __________ and coincides with the ____ wave if the patient is on an ECG monitor.
Apex, base, carotid artery, R
400
To learn about a patient's history of claudication, what question should the RN ask? A) when you first stand up, do you feel dizzy or light-headed? B) can you feel your pulse pounding after vigorous activity? C) have you experienced any leg cramping or pain in your legs? D) do you gave an urge to move your legs a lot during to night?
C
500
What type of questions would you ask a patient in order to gain subjective and objective data about the head, face, and neck?
Subjective: ask about headache, head injury, dizziness, neck pain, limited ROM, lumps, swelling, or a h/o head or neck surgery. Objective: inspect and palpate the skull, observe its size and shape, note any deformities, lumps, or tenderness, and palpate the temporal artery and temporomandibular joint.
500
Contrast the motions used to straighten the ear canal when using the otoscope with an infant versus an adult.
When using an otoscope for examination of an infant or child younger than age 3, pull the pinna straight down to match the slope of the ear canal. For an adult, pull the pinna up and back.
500
List and describe the 3 types of normal breath sounds.
1. Bronchial - high pitched, loud, harsh. Inspiration is shorter than expiration. Heard over the trachea and larynx. 2. Bronchovesicular - moderate sound. Inspiration is equal to expiration. Heard over major bronchi, between scapulae (R), upper sternum, and 1st/2nd intercostal. 3. Vesicular - low pitched, soft, rustling. Inspiration is longer than expiration. Heard over peripheral lung fields.
500
On auscultation, the RN hears a swooshing sound that coincides with S1 while listening with the diaphragm of the stethoscope. How should the RN identify this sound? A) Diastolic murmur B) Systolic murmur C) S4 heart sound D) S3 heart sound
B
500
The RN is performing a modified Allen test. Which action(s) should the RN take? SATA. A) instruct the patient to make a fist several times for about 30 seconds. B) place the patient's hand in a dependent position C) obliterate the ulnar and radial pulses D) instruct the patient to flex all her fingers E) document that the test results show inadequate circulation to the hand if pinkness fails to return within 6 seconds
A, C, E