Ch 18 Health Assesment

Front 1

The clavicles extend from the acromion of the scapula to the part of the sternum termed the _________________

Back 1

Manubrium

Front 2

The bony ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal

Back 2

Notch

Front 3

The spinous process termed the vertebra prominence is in which cervical vertebra?

Back 3

7th

Front 4

The apex of each lung is located at the ____________

Back 4

Area slightly above the clavicle

Front 5

The thin double layer of serous membrane that lines the chest cavity is termed _____________

Back 5

Parietal pleura

Front 6

The lining of the trachea and bronchi which serves to remove dust foreign bodies and bacteria is termed the ________

Back 6

Cilia

Front 7

Under normal circumstances the strongest stimulus in the human being to breathe is _____________

Back 7

Hypercapnia

Front 8

When assessing an adult client the client tells the nurse that she has difficulty catching her breath since yesterday the nurse should assess the client for further signs and symptoms of _____________

Back 8

Infection

Front 9

An adult client visists the clinic and tells the nurse that he has been sitting up rust colored sputum the nurse should refer the client to the physician for possible ______________

Back 9

Tuberculosis

Front 10

While assessing an adult client the nurse observes decreased chest expansion at the bases of the clients lungs the nurse should refer the client to a physician for possible _____________

Back 10

Chronic obstructive pulmonary disease

Front 11

The nurse is planning the percuss the chest of an adult male client for diaphragmatic excursion. The nurse should begin the assessment by?

Back 11

Asking the client to exhale forcefully and hold his breath.

Front 12

The nurse is preparing to auscultate the posterior thorax of and adult female client. The nurse should?

Back 12

Ask the client to breathe deeply through her mouth.

Front 13

While assessing the thoracic area of an adult client the nurse plans to auscultate for voice sounds to asses the bronchophony the nurse should ask the client to ?

Back 13

Repeat the phrase 99

Front 14

The nurse assesses an adult clients thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the clients?

Back 14

Pectus excavatum

Front 15

The nurse assess an adult client and observes that the clients breathing patteren is very labored and noisy with occasional coughing. The nurse should refer the client to a physician for possible?

Back 15

Chronic bronchitis

Front 16

While assessing and adults clients lungs during the postoperative period the nurse detects coarse crackles. The nurse should refer the client to a physician for possible?

Back 16

Pneumonia

Front 17

The nurse assesses an adults patients breath sounds and hears sonorous wheezes primarily during the clients expiration. The nurse should refer the client to a physician for possible?

Back 17

bronchitis

Front 18

The nurse has assed the respiratory pattern of an adult client. The nurse determines that the clients is exhibiting Kussmauls respirations with hyperventilation. The nurse should contact the clients physician because this type of respiratory pattern usually indicates ?

Back 18

Diabetic ketoacidosis

Front 19

High pitched short popping sounds

Back 19

Crackles (fine)

Front 20

Forward protrusion of the sternum

Back 20

Pectus carinatum

Front 21

High pitched musical sounds

Back 21

Wheeze (sibilant)

Front 22

An increased in carbon dioxide in the blood

Back 22

Promotes the strongest stimulus to breathe

Front 23

Low pitched bubbling moist sounds

Back 23

Crackles (coarse)

Front 24

Low pitched snoring or moaning sounds

Back 24

Wheeze (sonorous)

Front 25

Difficulty breathing when lying supine

Back 25

orthopnea

Front 26

Markedly sunken sternum and adjacent cartilage

Back 26

pectus excavatum

Front 27

Low pitched dry grating sound

Back 27

Pleural friction rub

Front 28

A crackling sensation

Back 28

crepitus

Front 29

___________ identifies the portion of the body extending from the base of the neck superiorly to the level of the diaphragm inferiorly.

Back 29

Thorax

Front 30

The lungs, distal portion of the trachea and the bronchi are located in the thorax and make up the ________________ system

Back 30

Lower respiratory system

Front 31

The _________ is constructed of the sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles and cartilage.

Back 31

Thoracic cage

Front 32

What is the function of the thoracic cage?

Back 32

It provides support and protection for many important organs.

Front 33

The ______________ aka breast bone lies in the center of the chest anteriorly and is divided into three parts.

Back 33

Sternum

Front 34

What are the three parts of the Sternum?

Back 34

Manubrium

Body of the sternum

Xiphoid process

Front 35

This is the U shaped indention located on the superior border of the manubrium

Back 35

Suprasternal notch

Front 36

A few centimeters below the suprasternal notch, a bony ridge can be palpated at the point where the manubrium articulates with the body of the sternum. This landmark is referred to a the __________

Back 36

Sternal angle

Front 37

The sternal angle is also known as the ________________

Back 37

Angle of louis

Front 38

The angle of Louis or sternal angle is also the location of the second pair of ribs and comes a reference point to count the spaces in-between the ribs known as_____________

Back 38

Intercostal spaces (The yummy part of BBQ ribs)

Front 39

How many pairs of ribs make up the main structure of the thoracic cage? Anterior and posterior

Back 39

10 Anterior ribs all connected to the sternum and vertebra

Posterior all 10 from front plus to more sets of floating ribs.

For a total of 12 sets of ribs.

Front 40

The first set of ribs is located?

Back 40

They curl up just under the clavicles, and only a small part can be palpable.

Front 41

The second pair of ribs is located?

Back 41

Adjacent to the sternal angle.

Front 42

Explain how to find rib sets 2-6, 7-10, and 11and 12.

Back 42

Set 2-6 located easy to count anteriorly and rib six is almost in line with the xiphoid process.

Ribs 7-10 connects to cartilages to the pair lying superior to them rather than to the sternum.

Ribs 11 and 12 are floating ribs because they do not connect to either the sternum or the ribs anteriorly.

Front 43

On the anterior chest these lines are known as ________ _______ and ___________

Back 43

Midsternal line and the right and left midclavicular lines

Front 44

The posterior thorax includes the ____________, ___________ and _________

Back 44

Vertebral or spinal line and the right and left scapular lines.

Front 45

The ___________ runs from the apex of the axillae to the level of the 12 rib.

Back 45

Midaxillary line

Front 46

What does the thoracic cavity consist of?

Back 46

Mediastinum and the lungs

Front 47

The _______ of each lungs extends slightly above the clavical

Back 47

Apex

Front 48

The base of the lungs are at the level of the _____________

Back 48

Diaphragm

Front 49

Lines that divide the lungs into lobes called ___________

Back 49

Fissures

Front 50

The right lung is made up ____________ lobes where as the left lung contains _____________ lobes.

Back 50

Right 3 lobes Left 2 lobes

Front 51

The thoracic cavity is lined by a thin double layered serous membrane collectively referred to as the _________

Back 51

Pleura

Front 52

The __________ pleura lines the chest cavity and the _______ pleura cover the external surface of the lungs.

Back 52

Parietal pleura and the visceral pleura

Front 53

The space between the two layers is known as __________

Back 53

Pleural space

Front 54

The pleural space is fluid with this lubricating fluid

Back 54

Serous fluid

Front 55

This is the flexible structure that lies anterior to the esophagus begins a the level of the cricoid cartilage in the neck. In adults it is around 10 to 12 cm long.

Back 55

Trachea

Front 56

These are C shaped rings that make up the cartilage of the trachea.

Back 56

Hyaline cartilage

Front 57

What is the function fo Hyaline cartilage?

Back 57

To help maintain shape and prevent the trachea from collapsing during respiration.

Front 58

At this level of the sternal angle the trachea divides into the left and right main _____________

Back 58

Bronchi

Front 59

The __________ main bronchus is shorter and more vertical than the __________ main bronchus

Back 59

Right is shorter than the left

Front 60

The trachea and the bronchi are lined with a mucous membrane containing _____________

Back 60

Cilia

Front 61

What is the function of cilia?

Back 61

Hair like projections that help sweep dust and foreign bodies and bacteria that have been trapped by the mucus toward the mouth for removal.

Front 62

Bronchi divided into smaller passage ways known as ___________

Back 62

Bronchioles

Front 63

Bronchioles split into break further down into this __________

Back 63

Alveolar ducts

Front 64

These are the little sacs located a the end of the alveolar ducts

Back 64

Alveolar sacs

Front 65

What is the function of alveolar sacs?

Back 65

Serve it increase surface area available for gas exchange

Front 66

When the alveolar sacs have collapsed it is known as ___________.

Back 66

Atelectasis

Front 67

____________ is difficulty breathing and can indicate a number of health problems most of which are related to the respiratory system

Back 67

Dyspnea

Front 68

Periods of breathing cessation during sleep

Back 68

Sleep apnea

Front 69

True or false

Pain sensitive nerve ending are located int eh parietal pleura thoracic muscles and tracheobronchial tree but not in the lungs.

Back 69

True

Front 70

True or false

Chest pain related to pleuritis may be absent in older adults due to age related alteration of pain perception.

Back 70

True

Front 71

____________ coughs are usually associated with acute infections.

Back 71

Continuous

Front 72

Early morning coughing is associated with ________________

Back 72

Chronic bronchial inflammation or smoking.

Front 73

Late evening coughing may be due to ____________

Back 73

exposure of irritants during the day.

Front 74

Night coughing is related to ____________ most of the time

Back 74

postnasal drip or sinusitis

Front 75

True or false

The ability to cough effectively may be decreased in the older client because of weaker muscles and increased rigidity of the thoracic wall

Back 75

True

Front 76

True or false

Nonproductive coughs are often associated with upper respiratory irritations and early congestive heart failure.

Back 76

True

Front 77

White or __________ sputum is often seen with common colds viral infections or bronchitis

Back 77

Mucoid

Front 78

Yellow or green sputum indicates?

Back 78

Bacterial infections

Front 79

Blood in the sputum is known as ___________

Back 79

hemophtysis

Front 80

Rust colored sputum indicates?

Back 80

Tuberculosis or pneumococcal pneumonia

Front 81

____________ indicates narrowing of the airways due to spasm or obstruction of the air way and is associated with CHF asthma,or excessive secretions

Back 81

Wheezing

Front 82

True or false
Asthma symptoms may mimic symptoms commonly associated with emphysema or heart failure.

Back 82

True

Front 83

What is SARS and who is at higher risk for it

Back 83

Severe Acute Respiratory Syndrome. Anyone traveling to mainland China, Hong Kong, Hanoi, Vietnam, Singapore, or Toronto Canada.

Front 84

This is caused by histoplasmosis a systemic fungal disease that is common in the rural midwestern US

Back 84

Histoplasma capsulatum

Front 85

Can SOB be manifested by stress?

Back 85

Yes

Front 86

_____________ is seen when labored respiration and is indicative of hypoxia

Back 86

Nasal flaring

Front 87

________ lip breathing may be seen in asthma and emphysema or CHF as a physiologic response to help slow down expiration and keep the alveoli open longer.

Back 87

Pursed lip breathing

Front 88

_____________ is a increased curve of the thoracic spine and is common in older adults

Back 88

Kyphosis

Front 89

True or false

Pale or cyanotic nails may indicate hypoxia

Back 89

True

Front 90

The ____________ muscles are used to facilitate inspiration increases of acute and chronic airway obstruction.

Back 90

Trapezius or shoulder

Front 91

When a client leans forward and uses arms to support weight and lift chest to increase breathing capacity this is known as _____________

Back 91

Tripod position often seen in COPD patients

Front 92

12 to 20 Respirations per min.

Back 92

Normal breathing pattern

Front 93

Patient is running a fever of 102, is anxious, and respirations are 24 breaths per min what kind of breathing pattern is this?

Back 93

Tachypnea

Front 94

Patient enters the ER and is supected of an drug over dose. Respirations are 10 breaths per min. What Breathing pattern is this?

Back 94

Bradypnea

Front 95

What are Kussmauls respirations?

Back 95

Hyperventilation associated with diabetic ketoacidosis, or CNS problems, or drug overdose.

Front 96

These respirations are at a decreased rate, depth, and of irregular pattern

Back 96

Hyporventilation. Usually the result of a narcotics or anesthetics overdose.

Front 97

This breathing pattern is regular caharacterized by alternating period of deep rapid breathing followed by periods of apnea. (typically see this when someone is about to code)

Back 97

Cheyne stokes respirations

Front 98

Irregular breathing pattern characterized by varying depth and rate of respirations followed by periods of apnea. Seen with meningitis or severe brain damage

Back 98

Biots respirations.