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143 Cards in this Set
- Front
- Back
Nurses use physical assessment skills to do what 5 things?
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1. develop and expand the database
2. identify and manage a variety of patient problems 3. evaluate the effectiveness of nursing care 4. enhance the nurse-patient relationship 5. make clinical judgments |
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Data relayed by the patient is known as what?
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subjective data
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Data observed by the nurse is known as what?
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objective data
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What are 3 things you should do to prepare for an assessment?
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1. explain to the patient where, when, and why the assessment will take place
2. help the client prepare (void, dress, etc.) 3. prepare the environment (lighting, temperature of the room, equipment, drapes, privacy) |
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_________ is a critical phase of assessment, and can be done alone or with other assessment techniques.
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Inspection
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What are 5 guidelines for inspection?
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1. take time to "observe" with you eyes, ears, and nose
2. use good lighting 3. look at color, shape, symmetry, and position 4. smell odors from skin, breath, and wounds 5. develop and use nursing skills |
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True/False:
Inspection should be done prior to any other assessment technique. |
False- while inspection can be done alone, it is often coupled with other assessment techniques
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(def)
light and deep touch |
palpation
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What part of the hand should you use to assess skin temperature?
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back of the hand
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What part of the hand should you use to assess texture, moisture, and areas of tenderness?
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fingers
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What 3 things should you note when assessing lesions?
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- size
- shape - consistency |
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(def)
a palpable vibration in the body |
tactile fremitus
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What portion of the hand should you use when assessing tactile fremitus?
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the ulnar portion of the hand
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(def)
sound produced by striking body surface |
percussion
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Percussion produces different notes depending on what?
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the underlying mass
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_______ is used to determine the size and shape of underlying structures by establishing their borders and indicates if the tissue is air-filled, fluid-filled, or solid.
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percussion
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(def)
listening to sounds produced by the body |
auscultation
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(def)
listening to sounds that are audible without a stethoscope |
direct auscultation
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(def)
listening to sounds with a stethoscope |
indirect auscultation
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Sounds observed during assessment (with or without a stethoscope) should be documented with what specific, descriptive information? (5)
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1. frequency
2. pitch 3. intensity 4. duration 5. quality |
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The flat diaphragm of a stethoscope picks up _____ -pitched respiratory sounds best.
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high
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The bell portion of a stethoscope picks up _____-pitched sounds such as heart murmurs.
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low
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Nursing history is _______ (subjective/objective).
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subjective
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When performing a review of systems, the nurse documents that the patient has a history of seizures and bipolar disorder. Is this information subjective or objective?
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This information is subjective. Any information given to the nurse by the patient is considered subjective.
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During assessment, the nurse documents the patient's BP as 137/98. Is this information subjective or objective?
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Objective
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A physical exam should be performed in what order?
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cephalocaudal, or head-to-toe in systemic order
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What is the order of physical assessment techniques?
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IPPA (Inspection, Palpation, Percussion, Auscultation)
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What type of physical assessment information is included in a general survey? (18)
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- general appearance, gait, nutritional status, state of dress, body build, any obvious disability, speech patterns, mood, hygiene, body odor, posture, race, gender, height, weight AND vital signs
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The integumentary system includes ____, ____, and ____.
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skin, hair, and nails
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True/False:
Percussion is rarely used to inspect the skin. |
True
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A blanch test (capillary refill) with results of >3 seconds indicates what?
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poor arterial circulation
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(def)
loss of normal angle between nail and nail bed due to chronic oxygen deprivation |
clubbing
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What technique(s) are used to assess the skin?
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inspection and palpation
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What technique(s) are used to assess the hair and nails ?
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inspection and palpation
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What chart is used to assess visual acuity?
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Snellen Chart
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When assessing the head, you should specifically observe what? (3)
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size, shape, and symmetry
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You should inspect and palpate what areas the eyes?
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- inspect and palpate lids and lashes
- inspect eye position and symmetry - inspect position, symmetry and size of the pupils |
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With Snellen chart results, the first number is what?
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the distance from the chart
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With Snellen chart results, the second number is what?
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the distance at which a "normal" eye could have read that line
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If an eye exam results have the abbreviation cc, this means what?
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that the exam with done with corrective lenses/glasses
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When assessing the eyes, what test is used for distance? What test is used for near vision?
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Snellen for distance
Rosenbaum for near vision |
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A visual field test assesses what?
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peripheral vision
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The extraocular muscle function testing (6 ocular movements) specifically assesses what?
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CN 3, 4, and 6
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When checking the pupils response to light and accommodation, the pupils should _______ (dilate or constrict) for light and near vision.
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constrict
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When checking the pupils response to light and accommodation, the pupils should _______ (dilate or constrict) for dimness and distance.
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dilate
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Describe the difference between direct and consensual pupil response.
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Direct= the eye being tested responds accordingly
Consensual= the eye opposite the one being tested responds accordingly |
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What is the Romberg test and what does it assess?
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a neurological test to detect poor balance and assess coordination (specifically, it detects the inability to maintain a steady standing posture with your eyes closed)
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Describe how to perform the Romberg test.
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- Have the patient stand still with their heels together.
- Ask the patient to close their eyes - If the patient loses their balance, the test is positive |
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Abnormalities in what (3) skills will be revealed with evaluation of heel-to-toe walking?
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- coordination
- balance - ability to perform skilled movements |
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dichotomy
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branching into two
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Ethanol intoxication, weakness, poor position sense, vertigo and leg tremors must be excluded before unbalance seen in the heel-to-toe test can be attributed to what?
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cerebellar lesion
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Deep tendon reflexes include which ones? (5)
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- triceps
- biceps - brachioradialis - patellar - achilles tendon |
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What deep tendon reflexes are we expected to be able to assess in NAC1?
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patellar and achilles reflexes
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Explain how to test deep tendon reflexes.
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- Compare symmetry of reflex on each side of the body
- Extremity to be tested should be completely relaxed and and slightly extended - Hold the reflex hammer loosely, allow it to swin freely in an arc |
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Which reflex grade:
Complete Absence |
0
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Which reflex grade:
Diminished |
1
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Which reflex grade:
Normal reflex |
2
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Which reflex grade:
Hyperactive |
3
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Which reflex grade:
Clonus present |
4
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(def)
a series of involuntary muscular contractions due to sudden stretching of the muscle |
Clonus
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Clonus is a sign of what?
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Certain neurological conditions (specifically upper motor neuron lesions such as stroke, multiple sclerosis, or spinal cord damage)
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How do you assess the motor function of the radial nerve?
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have the client move the wrist back and forth
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How do you assess the motor function of the median nerve?
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have the client perform thumb opposition with the remaining 4 fingers
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How do you assess the motor function of the ulnar nerve?
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abduction of fingers (spread fingers apart)
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True/False:
You should have the patient close their eyes when you assess the motor function of the nerves. |
False- you have the patient close their eyes for sensory function, not motor
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How do you assess the motor function of the femoral nerve?
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have the patient perform a straight leg raise
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How do you assess the motor function of the tibial nerve?
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have the client plantar flex the foot
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How do you assess the motor function of the peroneal nerve?
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have the client dorsiflex the foot
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How do you assess the sensory function of the femoral nerve?
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stroke the anterior thigh
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How do you assess the sensory function of the tibial nerve?
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stroke the sole of the foot
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How do you assess the sensory function of the peroneal nerve?
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stroke the web space between the first and second toe
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What assessment techniques are used to assess the ear?
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inspection and palpation, gross hearing tests (normal voice, whisper test, Weber and Rinne)
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What diagnostic test?
a vibrating tuning fork is placed in the middle of the forehead,chin, head equidistant from the patient's ears. The patient is asked to report in which ear the sound is heard louder. |
Weber
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What diagnostic test?
performed by placing a vibrating tuning fork initially on the mastoid process until sound is no longer heard, the fork is then immediately placed just outside the ear. Normally, the sound is audible at the ear. |
Rinne Test
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What assessment techniques are used for the throat and neck?
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inspect, palpate, and auscultate
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When assessing the neck, the trachea should be ________.
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midline
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When assessing the neck, you should auscultate the carotids. What are you listening for?
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bruits
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If a bruit is heard when assessing the neck, you should palpate it for what?
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a carotid thrill
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Describe normal vesicular lung sounds.
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soft and low
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Describe normal bronchial lung sounds.
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harsh and hollow
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Describe normal bronchovesicular lung sounds.
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mixed sound (b/t bronchial and vesicular)
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What is the purpose of assessing chest expansion?
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it determines symmetry of expansion and movement at the level of the diaphragm
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Describe how to assess chest expansion.
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place hands over the lower anterior chest wall along the costal margin and move them inward until the thumbs meet at the midline. When the patient breathes, the thumbs should separate at least 1 inch.
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Describe how to assess tactile fremitus posteriorly.
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Place hand on the back with fingers spread. Have the patient say "99" as hands move down the patient's back.
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If fremitus increases as you move down the patient's back, it indicates what?
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liquid or solid inside of the lungs
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If fremitus decreases as you move down the patient's back, it indicates what?
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normal findings
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What assessment techniques are used to assess the lungs?
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- inspect, palpate, percuss, and auscultate
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What is the normal note heard when percussing the lungs?
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resonance
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When auscultating the lungs, what is considered normal findings?
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clear and equal bilaterally
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For lung assessments, you should assess and document what three things?
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rate, rhythm, and effort
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What are 5 signs of respiratory problems?
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1. anxious expression
2. suprasternal and intercostal retractions 3. nasal flaring 4. circumoral cyanosis 5. hyperexpanded chest |
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You should auscultate breath sounds with the _______ of the stethoscope.
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diaphragm
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Abnormal breath sounds are called what?
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adventitious sounds
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(def)
shrill, harsh sound heart on inspiration due to laryngeal obstruction |
stridor
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(def)
a high-pitched squeaky breath sound usually not changed by coughing |
wheeze
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If a wheeze is detected, what specific information should be documented?
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- whether heard with or without a stethoscope
- if heard of inspiration, expiration or both - if cleared with coughing |
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Give 2 examples of disorders that cause wheezing.
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- asthma
- foreign body aspiration |
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Crackles are most commonly heard in what part of the lungs?
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bases
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Crackles are more easily heard on ________ (inspiration or expiration), however they occur in both.
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inspiration
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(def)
grating, creaking, or rubbing sound heard on both inspiration and expiration; not relieved by coughing |
friction rub
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A friction rub is due to what?
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pleural inflammation
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What are 8 common site for palpating a pulse?
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1. carotid
2. brachial 3. radial 4. ulnar 5. femoral 6. popliteal 7. posterial tibial 8. dorsalis pedis |
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What pulse rating?
absent |
0
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What pulse rating?
Weak |
1+
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What pulse rating?
Normal |
2+
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What pulse rating?
Increased |
3+
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What pulse rating?
bounding |
4+
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Where should the hand be placed to palpate the precordium?
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5th intercostal space, mid clavicular line
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What are the 2 types of edema?
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pitting and non-pitting
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What Edema Scale rating?
slight |
+1
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What Edema Scale rating?
Noticeable |
+2
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What Edema Scale rating?
Deep |
+3
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What Edema Scale rating?
Remarkable |
+4
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Describe how to auscultate the aortic area of the heart.
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Listen with the diaphragm at the right 2nd intercostal space near the sternum
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Describe how to auscultate the pulmonic area of the heart.
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listen with the diaphragm at the left 2nd interspace near the sternum
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Describe how to auscultate the tricuspid area of the heart.
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listen with the diaphragm at the left 4th interspace near the sternum
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Describe how to auscultate the mitral area of the heart.
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Listen with the diaphragm at the apex of the heart (5 LICS MCL)
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After assessing the aortic, pulmonic, tricuspid, and bicuspid areas of the heart with the diaphragm, you should listen with the bell at the ______.
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apex
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When assessing abnormal heart sounds, you should listen with the _____ at the left 4th and 5th interspace near the sternum.
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bell
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Where should you listen to the heart when assessing abnormal heart sounds?
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left 4th and 5th interspace near the sternum
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How should you position the patient to assess S3 and mitral murmurs?
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have the patient roll on their left side and listen with the bell at the apex
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How should you position the patient to assess aortic murmurs?
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- have the patient sit up, lean forward and hold their breath on exhalation
- listen with the diaphragm at the left 3rd and 4th interspace near the sternum |
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To best hear aortic murmurs, you should listen to the heart where?
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at the left 3rd and 4th interspace
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Leaning the patient forward accentuates what heart sounds?
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aortic and pulmonic
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Lying a patient in left lateral decubitus position accentuates what heart sounds?
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those produced at the mitral area
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Describe S1 sounds.
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- Soft, lubb sound
- first heard sound |
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The S1 sound is caused by the closure of what?
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The tricuspid and mitral valves
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Where is S1 best heard?
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at the apex
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Describe S2 sounds.
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- Sharp, dupp sound
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Where is S2 heard best?
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at the aortic area
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S2 is caused by the closure of what?
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the aortic and pulmonic valves
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S2 is the beginning of what?
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diastole
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(def)
a difference in the valve closure time of the tricuspid and mitral valves |
S1 split
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An S1 split is heard best at which ICS?
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4th
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(def)
a difference in the valve closure time of the aortic and pulmonic valves of the heart |
S2 split
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(def)
heart sound described as a low-intensity vibration of the ventricular walls associated with ventricular filling |
S3
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Are audible S3 sounds ever normal?
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yes, in healthy children and young adults
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(def)
Low-frequency vibration caused by atrial contraction |
S4
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When do S4 sounds occur?
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in the later part of diastole but preceding S1 of the next cycle
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What are heart murmurs?
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an increased flow of blood through the normal structures of the heart
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Heart murmurs are graded on a ___ point scale.
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six
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(def)
an extra heart sound of to-and-fro character, typically with three components, one systolic and two diastolic. It resembles the sound of squeaky leather and often is described as grating, scratching, or rasping. |
pericardial friction rub
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(def)
a crunching, rasping sound, synchronous with the heartbeat |
mediastinal crunch
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