S17 Assessment Final Exam

Front 1

What are the five vital signs?

Back 1

Blood Pressure, Pain, Temperature, Respirations, and Pulse.

Front 2

What is a bruit?

Back 2

Swooshing sound.

Front 3

What is crepitation?

Back 3

A crackling sound.

Front 4

What is an occlusion?

Back 4

Closing off of something.

Front 5

What is the normal costal angle?

Back 5

90 degrees.

Front 6

What are the normal assessment techniques?

Back 6

Inspection, palpitation, percussion, and auscultation.

Front 7

What are factors that affect blood pressure?

Back 7

Elasticity of arteries, cardiac output, blood volume, velocity/viscosity, resistance, weight, age, ETOH, stress, gender, race, and exercise.

Front 8

What part of the heart are considered the muscular pumping chambers?

Back 8

The Ventricles.

Front 9

What is the thin membrane that lines the ventricles, atrium, and valves?

Back 9

The endocardium.

Front 10

What is the reservoir in the heart that holds the blood?

Back 10

The atrium.

Front 11

What is the muscular wall of the heart called?

Back 11

The myocardium.

Front 12

What is the tough, fibrous, double walled sac that contains the heart called?

Back 12

The pericardium.

Front 13

What is the pericardium composed of?

Back 13

Fibrous and serous layers with the fibrous layer being superficial to the serous layer.

Front 14

Where are the atrioventricular (AV) valves located?

Back 14

Entrance to ventricles.

Front 15

Which valve is composed of three cusps and is located between the right atrium and right ventricle?

Back 15

Tricuspid vavle.

Front 16

Which valve is composed of two cusps and is located between the left atrium and left ventricle.

Back 16

Bicuspid or mitral valve.

Front 17

Which valves are located at the exit of each ventricle at the beginning of the great vessels?

Back 17

Semilunar valves.

Front 18

Which valve is located at the entrance of the pulmonary artery as it exits the right ventricle?

Back 18

Pulmonic valve.

Front 19

Which valve is located at the beginning of the ascending aorta as it exits the left ventricle?

Back 19

Aortic valve. Best heard at left second intercostal.

Front 20

What produces heart sounds?

Back 20

Valve closure. Best heart at right second intercostal.

Front 21

What produces the S1 sound?

Back 21

AV valve closure.

Front 22

What produces the S2 sound?

Back 22

Semilunar valve closure.

Front 23

Where is the S1 sound best heard?

Back 23

Apex of the heart.

Front 24

Where is the S2 sound best heard?

Back 24

Base of the heart.

Front 25

What is another name for the S3 sound?

Back 25

Ventricular gallop.

Front 26

What is the best place to hear the apical pulse?

Back 26

Mid-clavicular 5th intercostal.

Front 27

If you hear a murmur after S1 but before S2 is it systolic or diastolic?

Back 27

Systolic and it would be pathological.

Front 28

What increases your risk for heart disease?

Back 28

Smoking, obesity, diabetes, hypertension.

Front 29

When can the S3 sound be heard?

Back 29

After S2 in early diastole.

Front 30

When can the S4 sound be heard?

Back 30

After S3 and late in diastole.

Front 31

What is another name for the S4 sound?

Back 31

Atrial gallop and is secondary to ventricular resistance.

Front 32

What are murmurs?

Back 32

Turbulent blood flow caused by various conditions. Sound like a whooshing or blowing sound over the pericardium.

Front 33

What conditions contribute to turbulent blood flow?

Back 33

Increased blood velocity, structural valve defects, valve malfunction, and abnormal chamber openings (septal defect)

Front 34

What is a regular heart rhythm?

Back 34

60-100 BPM

Front 35

What is a systolic murmur?

Back 35

Heard between S1 and S2 and it is pathologic.

Front 36

What are clinical manifestations of heart failure?

Back 36

Dyspnea, tachycardia, fatigue, orthopnea, pulmonary and peripheral edema, nocturia, decreased O2 sat, distended jug, decreased cardiac output, weak pulse, dry cool skin, high or low BP, cough, crackles, or wheezes.

Front 37

What is the number one risk for having heart disease?

Back 37

Family history.

Front 38

What are the palpable pulses?

Back 38

Carotid, radial, ulnar, brachial, apical, femoral, popliteal, dorsalis pedis, posterial tibial (in order).

Front 39

What are the levels of pulse strength?

Back 39

+1=weak and barely palpable

+2=normal

+3=between bounding and normal

+4=bounding

Front 40

What is a VLU?

Back 40

Venous leg ulcer and the most common type of skin ulcer. The skin breaks down to reveal underlying flesh. It is caused by increased pressure of blood in the veins in the lower legs. Usually painless. Obesity. Superficial craters, warm feet, swelling.

Front 41

What is an arterial ulcer?

Back 41

Results from inadequate blood supply, usually as a result of atherosclerosis,. Painful and located on toes, foot, or lateral ankle. Caused by skin shrinking to due lack of blood supply. Skin is taught and shiny. Atrophy of the skin.

Front 42

What is a DVT?

Back 42

Deep venous thrombosis caused by peripheral edema. Risk factors include reduced mobility, dehydration, increased blood viscosity, and venous stasis. Deep vein blood clots. Mainly affects lower legs and thighs. Homan's sign indicates a DVT.

Front 43

If a patient raises their leg and its white what type of problem is occurring?

Back 43

An arterial problem. Lack of blood flow.

Front 44

If a patient has swelling in their legs what type of problem is it?

Back 44

A venous problem. Blood pooling.

Front 45

If a patient has superficial craters in their legs, what type of problem is it?

Back 45

A venous problem.

Front 46

If a patient's skin is taught and shiny, what type of problem is it?

Back 46

Arterial problem. Lack of blood flow.

Front 47

What population is at greatest risk for developing ulcers?

Back 47

Obese people.

Front 48

If you patient has bilateral pitting edema, what problem are they most likely having?

Back 48

Heart failure.

Front 49

Where would you see rust colored sputum and night sweats?

Back 49

TB patient.

Front 50

What are precautions for a TB patient?

Back 50

Isolation, airborne precautions, wear a mask.

Front 51

What are the primary muscles for respiration?

Back 51

Diaphragm and intercostal muscles.

Front 52

How many lobes in the left lung?

Back 52

2 lobes.

Front 53

How many lobes in the right lung?

Back 53

3 lobes.

Front 54

How would you confirm chest wall symmetry?

Back 54

Place hand on T10 and view expansion, move your hand from one side to the other.

Front 55

What is air that passes through narrow bronchioles?

Back 55

Wheezing.

Front 56

Who has the greatest risk of breast cancer?

Back 56

African Americans.

Front 57

Best time to examine breasts for cancer?

Back 57

7 days after menstrual cycle.

Front 58

Why would you palpitate the lungs?

Back 58

For tenderness, crepitus, lesions, fremitus (vibrations), or chest expansion.

Front 59

A dull sound during lung percussion indicates what?

Back 59

Fluid in the lungs.

Front 60

What are the three breath sounds?

Back 60

Bronchial, bronchovesicular, and vesicular.

Front 61

How is bronchophony measured?

Back 61

Have the client say 99

Front 62

How is egophony measured?

Back 62

Have the client say E

Front 63

How is pectoriloquy measured?

Back 63

Have the client whisper 1-2-3

Front 64

What are adventitious sounds?

Back 64

Crackles or wheezes

Front 65

What is the nursing DX for TB?

Back 65

Impaired gas exchange.

Front 66

What is the most effective method for screening for breast cancer?

Back 66

An up to down vertical pattern from ribs to collarbone lying down with opposite arm above your head.

Front 67

How do cancerous tumors in the breast feel?

Back 67

Irregular, firm, hard not defined masses, may be fixed or mobile, not usually tender and occur after 50.

Front 68

How do fibroadenomas in the breast feel?

Back 68

Lobular, ovoid, or round. Firm, well-defined, slightly tender, and singular and mobile. Occur between puberty and menopause.

Front 69

What is fibrocystic breast disease?

Back 69

A benign breast disease most common from age 30 to menopause resulting in mobile cysts that are round, defined, and tender.

Front 70

What are increases to breast cancer?

Back 70

Female, older age, genetics, denser breasts, early menstruation, no children, contraceptive use, hormone replacements, no breast feeding, weight, no physical activity, and alcohol consumption.

Front 71

What is protuberant?

Back 71

A bulging and stretched abdomen.

Front 72

What is the nursing DX for alcohol abuse and not eating?

Back 72

Altered nutrition.

Front 73

How would you lower a patient's abdominal pain?

Back 73

Bend those knees yo.

Front 74

What are indicators of alcohol abuse?

Back 74

Black tarry poops, GI bleeding, etc.

Front 75

Where would you locate the abdominal pulsation?

Back 75

Between the xiphoid process and umbilicus. Hear it, don't see it.

Front 76

What is AAO?

Back 76

Alert and oriented to person, place, and time. Can be affected by O2.

Front 77

What are the Glascow scales for the eyes?

Back 77

1-No eye opening

2-Eye opening to pain

3-Eye opening to verbal command

4-Eye opening spontaneously

Front 78

What is the Glascow scale for verbal responses?

Back 78

1-No verbal response

2-Incomprehensible sounds

3-Inappropriate words

4-Confused

5-Oriented

Front 79

What is the Glascow scale for motor response?

Back 79

1-No motor response

2-Extension to pain

3-Flexion to pain

4-Withdrawel from pain

5-Localizes pain

6-Obeys commands

Front 80

What are the levels of muscle strength?

Back 80

0-no contraction

1-muscle flicker, but no movement

2-movement, but not against gravity

3-movement against gravity, but not resistance

4-movement against some resistance

5-normal strength

Front 81

What is the MAP?

Back 81

Mean arterial pressure, or the average pressure in the arteries over a certain period of time.

Front 82

What does the pulse oximeter measure?

Back 82

Arterial blood oxygenation

Front 83

What is the configuration of the thorax in a patient with scoliosis?

Back 83

Curved, it deviates laterally into the posterior thoracic area.

Front 84

What is intermittent claudication?

Back 84

Characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks. May indicate peripheral artery disease.

Front 85

What is the range of the normal liver span in cm in an adult?

Back 85

6-12 cm.

Front 86

What is shifting dullness a test for?

Back 86

The presence of ascites or intraperitoneal fluid.

Front 87

What is Murphy's sign?

Back 87

A test for gallbladder disease in which the patient is asked to inhale while the examiner's fingers are hooked under the liver border at the bottom of the rib cage.