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126 Cards in this Set
- Front
- Back
The strongest stimulus to breathe ?
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an increase of carbon dioxide.
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types of posterior chest configurations.
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scoliosis
barrel chest |
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IF you hear an abnormal sound during auscultation, what should the nurse have the client do?
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have the client cough, then listen again and note any change.
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Breath sounds heard when assessing the posterior chest?
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vesicular and bronchovesicular
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Breath sounds heard while assessing the anterior chest ?
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bronchial
vesicular bronchovesicular |
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IF you hear an abnormal sound during auscultation, what should the nurse have the client do?
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have the client cough, then listen again and note any change.
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adventitious sounds
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crackles
wheezes |
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hyperresonance is elicited in cases of ?
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pneumothorax or emphysema
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When is dullness elicited?
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when fluid or solid tissue replaces air in he lungs or occupies the pleural space.
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Examples of dullness can be heard in clients who have?
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lobar pneumonia
pleura effusion tumor |
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external respirations
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ventilation
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Elderly consideration
Dyspnea related to activity |
loss of elasticity
fewer functional capillaries loss of lung resiliency |
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Dyspnea that occurs with edema or angina could indicate ?
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a cardiovascular problem
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Gradual onset dyspnea could indicate
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emphysema
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Sudden onset of dyspnea is associated with?
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viral or bacterial infection
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Orthropnea is associated with ?
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congestive heart failure
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Paroxysmal nocturnal dyspnea is associated with ?
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congestive heart failure
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Where can the pain sensitive nerve endings be found?
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parietal pleura
thoracic muscles tracheobronchial tree |
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Chest pain associated with pulmonary origin may be associated with ?
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pulmonary disease
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continuous coughs are associated with?
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acute infections
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coughs occurring early in the morning are associated with ?
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chronic bronchial inflammation or smoking
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coughs late in the evening are associated with?
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exposure to irritants
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coughs occurring at night are associated with?
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postnasal drip or sinusitis
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non-productive coughs are associated with ?
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upper respiratory irritation or early congestive heart failure
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Coughing
Elderly considerations |
coughs becomes less productive due to weaker muscles and increased rigidity of the thoracic wall
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white or mucoid sputum is associated with ?
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common cold
viral infections bronchitis |
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yellow or green sputum is associated with ?
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bacterial infections
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blood in the sputum AKA hemoptysis is associated with?
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serious respiratory conditions
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Rust colored sputum is associated with ?
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tuberculosis
pneumococcocal infection |
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Pink, frothy sputum may indicate?
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pulmonary edema
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Wheezing indicates?
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a narrowing of the airway due to spasm or obstruction
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Wheezing is associated with ?
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congestive heart failure= CHF
asthma=reative airway disease excessive secretions |
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Asthma symptoms may mimic the symptoms of ?
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emphysema or heart failure
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Thoracic surgery can alter ?
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the appearance of the thorax and changes in the respiratory sounds .
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Truama to the thorax can cause ?
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lung tissue changes
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Respiratory responses that are associated with allergic reactions are ?
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dyspnea
cough hoarseness |
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Second hand smoke puts an individual at risk for ?
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emphysema or lung cancer later in life
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Inhaling dust contaminated with Histoplasma capsulatum may cause?
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histroplamosis a systemic fungal infection
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Lung cancer
African American men |
have a higher incidence and mortality rate
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Lung cancer risk reduction teaching tips.
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stop smoking
diet=low cholesterol adequate vit. E and lutein limited exposure to pollution wear protective mask when necessary |
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The average age of lung cancer diagnosis ?
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60 years old
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Survival rate of lung cancer if detected early?
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5 year survival rate is 42% but only 15% of the cases are detected early
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The average age of lung cancer diagnosis ?
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60 years old
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How many years does it take for a smoker's who quits lungs to return to normal ?
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10 to 15 years.
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If a client is using oxygen at home the nurse should evaluate the client's ?
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knowledge of proper usage
precautions and ability to afford the therapy |
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Kyphosis
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an increased curve of the thoracic spine, is common is older adult. Results from a loss of skeletal muscle : it may be a normal finding
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Barrel chest
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Ribs appearing horizontal at an angle of greater than 45 degrees with the spinal column are often the result of an increased ratio between the anteroposterior-transverse diameter
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Barrel chest is common is clients with?
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emphysema due to hyper-inflation of the lungs
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To inspect the clients posterior chest configuration and scapulae the client is in what position?
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sitting with back to the nurse with arms at the side.
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A normal scapulae finding is ?
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non-protruding, shoulders and scapulae are at equal horizontal positions.
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What race have a larger thorax and greater lung capacity?
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adult Caucasians
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The use of trapezius, or shoulder, muscles are used in cases of ?
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atelectasis or chronic airway obstruction
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Tripod position is used by clients who suffer from?
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COPD
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Pain over the intercostal spaces indicates?
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inflamed pleurae
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Pain over the ribs, especially at the costal condral junctions is a symptom of ?
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fractured ribs
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Increased warmth while palpating the thorax indicated
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local infection
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What should a nurse do if he/she palpates an unusual mass?
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refer client to doctor for further evaluation
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How does the nurse palpate fremitus ?
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use the ball or ulnar of the hand starting left midline at the level of the scapula and proceeding from side to side areas just above the waist.
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palpating
symmetric expansion |
use both hands, thumbs together and fingers apart on the client's back below the lungs
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papating for sensations, lumps, and masses should be done with what part of the hands?
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fingers
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tactile fremitus may best be felt with ?
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heel of the hands or the base of the fingers
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Crepitus is AKA subcutaneous emphysema
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can be felt is air escapes from the lung or other airways into the subcutaneous tissues occurs with open thoracic injury or tracheostomy, or around a chest tube
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crepitus can be described as ?
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a crackling sensation - like hair or bones rubbing together. it occurs when air passes through fluid or exudate.
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If crepitus is palpated the nurse should ?
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mark he margins and monitor to note any decrease or increase in the crepitant area.
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IS crepitus a normal or abnormal finding ?
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abnormal
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What is fremitus ?
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vibrations of air in the bronchial tubes transmitted to the chest wall, felt by the examiner when the client says "ninety-nine"
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Normal fremitus is ?
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felt symmetric for bilateral positions.
decrease in the intensity as the examiner moves downward. symmetrical and easily identified in the upper regions. |
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Unequal fremitus is usually the result of ?
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consolidation that increases fremitus or bronchial obstruction, air trapping in emphysema, pleural effusion, or pneumothorax that decreases fremitus.
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Diminished fremitus even when spoken with a loud voice may indicate?
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an obstruction of the tracheobronchial tree.
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What should the nurse do if she cannot
palpate fremitus on either side? |
ask the client to speak louder.
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hands on the posterior chest wall
thumbs at the level of t9 or t10 ask client takes deep breath observe movement thumbs move 5-10 cm. |
palpte chest expansion
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decreased chest expansion at the base of the lungs is associated with?
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chronic obstructive pulmonary disease.
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unequal chest expansion is associated with ?
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severe atelectasis
pneumonia chest trauma or pneumothorax |
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How does the nurse percuss for tone on the posterior chest wall?
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start at apices above the scapula
across tops of both shoulders percuss the intercostal spaces across and down. compare sides |
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Is resonance a normal or abnormal finding ?
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NORMAL
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What is the normal tone that should be heard when percussing the chest?
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resonance
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hyperresonance is elicited in cases of?
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trapped air
examples are= emphysema or pneumothorax |
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Dullness is percussed in cases of ?
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fluid or solid tissue replaces air in the lung or occupies the pleural space
examples are= lobar pneumonia, pleural effusion, or tumor |
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diminished or absent breath sounds often indicate?
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little or no air movement in or out of the lungs being auscultated may indicate obstruction as a result of secretions, mucus plug, or a foreign object and may indicate abnormalities of the pleural space
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Sometimes breath sounds may be hard to hear because of ?
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a client is obese or heavily muscled due to increased distance to underlying tissue
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Diseases related to decreased or absent breath sounds ?
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pleural thickening
pleural effusion pneumothorax emphysema |
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When would a prominent sternum and ribs be a normal finding ?
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when assessing an elderly client. due to loss of subcutaneous fat.
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If the level of the diaphragm is higher on the right is this a normal or abnormal finding ?
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normal because of the position of the liver
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labored and noisy breathing is seen in clients with ?
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severe asthma
chronic bronchitis |
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normal respiration range
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10- 20 per minute
relaxed effortless quiet |
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Cheyne-Stokes breathing is heard in clients with ?
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congestive heart failure
drug overdose increased cranial pressure renal failure |
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Biot's breathing is associated with ?
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meningitis
severe brain damage |
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tachypnea
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> 24/min and shallow
normal response to fever, anxiety, or exercise. also occur with respiratory insufficiency alkalosis, pneumonia, or pleurisy |
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bradypnea
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< 10/min and regular
normal in athletes can occur with medication-induces coma, neurologic damage |
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Hyperventilation
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increased rate and increased depth
occurs w/ exercise, fear, anxiety can occur w. disorders of central nervous system, overdose of the drug salicylate, or severe anxiety |
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Kussmal's respirations is a type of hyperventilation see in clients with ?
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diabetic ketoacidosis
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Wheezes (sibilant) are heard in client's with ?
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acute asthma
chronic emphysema |
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Wheezes (sonorous) are heard in client's with?
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bronchitis or single obstructions and snoring before an episode of sleep apnea.
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Stridor is a harsh honking wheeze heard in clients with severe?
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broncholaryngospasm such as croup
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Pleural friction rub
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sound of the rubbing of two inflamed pleural spaces = pleuritis
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When is a pleura friction rub not heard?
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not heard if the client holds their breath.
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polycythemia
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ruddy
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cyanotic
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hypoxia
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bronchophony
abnormal |
client say ninety-nine
the words are easily understood and louder over areas of increased density. indicates consolidation from pneumonia, atelectasis, or tumor |
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egophony
abnormal |
client says "E"
over areas of consolidation or compression the sound will be louder and change to the letter "A" |
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whispered pectoriloquy
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client whispers he phrase one-two-three
over areas of consolidation or compression the sound will be transmitted clearly and distinctly |
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auscultating the posterior thorax the nurse starts ?
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the apex of the lung at C7
client will breathe deeply through his or her mouth for each area of auscultation. auscultate from C7 to T10 and laterally from the axilla down to the seventh or eighth rib |
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to auscultate the anterior thorax where does the nurse start?
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apices of the lungs, above the clavicles to the bases of the lungs at the sixth rib
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pectus excavatum
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funnel chest= sunken sternum= seldom causes problems
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pectus carinatum
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pigeon chest= sternum protrudes = requires no treatment
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bronchial breath sounds are heard?
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over the trachea and larynx
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bronchovesicular sounds are heard ?
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over the major bronchi
posterior= around the upper sternum anterior = around the upper sternum in the first and second intercostal space. |
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where are vesicular sounds are heard?
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peripheral lung fields
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thick and sticky secretions
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interventions for cough and thinning
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bronchial breath sounds
duration |
short during inspiration
long during expiration |
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bronchovesicular breath sounds
duration |
even on inspiration and expiration
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vesicular breath sounds
duration |
long during inspiration
short during expiration |
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crackles (fine)
characteristics |
high pitched
short popping sounds during inspiration not cleared with cough sounds like hair rubbing together |
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crackles (coarse)
characteristics |
low-pitched
bubbling moist persist from early inspiration to early expiration velcro separating |
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crackles (fine)
the source of? |
inhaled air suddenly opens the small deflated air passage that are coated and sticky with exudate
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crackles (coarse)
source |
inhaled air comes in contact with secretions in the large bronchi and trachea
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Wheeze (sibilant)
characteristics |
high pitched
musical during expiration |
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Wheeze (coarse)
characteristics |
low pitched
snoring or moaning may clear with coughing |
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sudden severe pain with dyspnea
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emboli
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pursed lip breathing is associated with ?
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asthma
emphysema or chronic heart failure it is a physiological response to slow down breathing |
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nasal flaring is associated with ?
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hypoxia
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SOB w/ mild exertion i.e. flight of stairs
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grade 1
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sob walking a short distance, level ground
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grade 2
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SOB minimal activity, i.e. shaving
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Grade 3
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SOB @ rest
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Grade 4
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Orthopnea, SOB while supine
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Grade 5
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