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Health Assessment Exam 3 Study Guide
Health Assessment (NURS 216)
Arizona College of Nursing
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Health Assessment Exam 3 Prep
Module 6- Reading o ATI: 29 o Health Assess: 5- o Basic: 38
Exam 3 study guide and Lung sound attachment
The nurse is performing a respiratory assessment and detects a low pitch, soft sound. The inspiratory phase is longer than expiration. The nurse interrupts this as: o Vesicular sound o Bronchovesicular o Bronchial o Tracheal o Answer: Vesicular sound
When percussing the chest, what sound would the nurse expect to hear over the lungs? o Resonance o Hyperresonance o Tympany o Dullness o Answer: resonance
The nurse auscultates an extra sound over the left lower lobe. The nurse should: o Document finding o Notify physician o Ask client to cough o Reassess in one hour o Answer: Ask client to cough Upon auscultation the nurse detects an extra gurgling, expiratory sound in the upper airways. The nurse interrupts this as: o Crackles o Rhonchi o Wheeze o Friction Rub o Answer: Rhonchi
Inspection of the chest includes assessing the anteriorposterior:lateral ratio. The normal finding for an adult is: o 1: o 1: o 1: o 1: o Answer: 1: The nurse is performing a cardiac assessment. Which site is best for palpating the PMI? o Left Base o Right Base o LLSB
o Apex o Answer: D- Apex
The nurse detects a trill while palpating the carotids. What sound would the nurse expect to hear when auscultating the carotids? o Bruit o Murmur o Venous Hum o No sound o Answer: A- Bruit
How would the nurse differentiate carotid from venous pulsations? o Jugulars unaffected by position o Jugulars affected by breathing o Jugular pulsation palpable o Jugulars have singular wave form o Answer: B- Jugulars affected by breathing
During cardiac auscultation, the nurse detects a low pitch early diastolic sound at the apex. The nurse interprets this as: o S 3 o S 4 o Ejection click o Opening Snap o Answer: A- S There are many different causes of chest pain. Which area should be addressed first when a client presents with chest pain? o Respiratory o Gastrointestinal o Musculoskeletal o Cardiac o Answer: D Cardiac
Test will describe a sound ie popping bubble sound and must identify what kind Auscultation- MUST KNOW BREATH SOUNDS FOR EXAM- know which sounds are where o Breath sounds: Vesicular- lung fields- mostly what we listen to Bronchovesicular- near sternal notch Bronchial- up by clavicle
Adventitious Sounds- MUST KNOW- will type up and send out sheet o Rales/crackles
o Elevated: 120-129/< o Stage 1: 130-139/80- o Stage 2: > or = 140/> = 90 o Hypertensive crisis >180/> o Hypotension: SBP <
Heart failure o Left-sided: blood backs up into the lungs (more common) Pulmonary congestion Cough Sputum- blood-tinged Tachypnea Tachycardia Restless Confusion Dyspnea- worse with exertion Cyanosis- check MM/sclera in patient with darker skin tone Fatigue Lung sounds: crackles and wheezes o Right-sided: blood backs up coronary vein Fatigue Increased JVD Ascites Hepatosplenomegaly Anorexia Weight gain Edema Hypertension modifiable and nonmodifiable risk factors o Modify- alcohol intake, smoking, stress o Nonmodifiable- family history, age
Peripheral artery disease- PAD o Hair loss on lower limbs o Weak or absent peripheral pulses o Ulcerations in toes and lower limbs that do not bleed o Pain with walking o Legs cool to the touch
Peripheral venous disease- PVD o Develop wounds that usually have drainage o Skin gets very thick and brown
How many lobes are in each lung? o Left-2 Right-
What is the order of techniques for the respiratory assessment? o Inspection, palpation, percussion, auscultation
What are the pleura, bronchi, bronchioles, and alveoli? o Pleura- lining of the lungs o Bronchi- major airway passages of the lungs o Bronchioles- smaller airway passages of the lungs
o Alveoli- location of gas exchange
Where can you check for cyanosis? o Conjunctiva and oral mucous membranes What lung changes occur in an older adult? o Loss of tissue elasticity- increased rigidity- difficult to inflate- increased risk for pneumonia What is the benefit of increased hydration to a pneumonia patient? o Thin secretions
Who is at increased risk for pneumonia? o COPD patients and older adults
What are typical subjective and inspection findings for a COPD patient? o Subjective: dyspnea, chronic productive cough, fatigue o Inspection: tachypnea, productive cough, clubbing of nails, increased AP diameter, accessory muscle use, short shallow breaths, prolonged expiration, O sat levels low-88-89% or even lower What are typical percussion and auscultation findings for a COPD patient? o Percussion: Decreased diaphragmatic excursion, hyperresonance due to trapped air o Auscultation: decreased breath sounds possible occasional wheeze and crackles
What is a side effect of opioids? o CNS depression- bradypnea, shallow respirations
What is a normal RR, bradypnea, and tachypnea? o Normal: 12-20 bpm o Bradypnea: < 12 bpm o Tachypnea: >20 bpm Where are bronchovesicular, bronchial, and vesicular sounds heard? o Bronchovesicular: over major bronchi o Bronchial: over trachea or larynx o Vesicular: over peripheral lung fields What are ways to prevent respiratory complications post op? o Encourage inspiratory spirometer (IS) every hour while awake o Brush teeth BID o Encourage the client to cough and deep breath o Sit in chair for each meal What is the order of techniques for cardiovascular assessment? o Inspection, palpation, auscultation
What do you need to do if the radial pulse is irregular? o Auscultate the apical pulse for a full minute What is a pulse deficit? o Difference between the radial and apical pulse
What do each of the pulse scores mean? o 0 – absent pulse o 1+ weak, diminished, thready o 2+ normal, brisk o 3+ full o 4+ bounding
o Murmurs- could indicate the presence of heart disease and valve malfunction
What 4 peripheral pulses can be palpated in the lower extremities? o A – femoral pulse o B – popliteal pulse o C – posterior tibial pulse o D- dorsalis pedis pulse
o
What symptoms would have higher priority than chest pain? o Airway and breathing- ex dyspnea o Chest pain abnormal cardiovascular finding and related to circulation
What do crackles/rales sound like and what are some causes of this? o Air bubbling through moisture in the alveoli. o Bubbling, crackling, popping. Soft, high-pitched, and very brief sounds o Usually heard during inspiration. o Pulmonary edema, pneumonia, atelectasis, fibrosis.
What do wheezes sound like and what are some causes of this? o Narrowing of small airways by spasm, inflammation, mucus, or tumor. o High-pitched musical or squeaking sounds heard during inspiration or expiration. o May clear with coughing. o Asthma, COPD.
What do rhonchi sound like and what are some causes of this? o Mucus secretions in the large airways. o Course, snoring, continuous low-pitched sounds heard during inspiration and expiration. o May clear with coughing. o Pneumonia, bronchitis, emphysema.
What does a stridor sound like and what are some causes of this? o Partial upper airway obstruction or tracheal or laryngeal spasm. o High-pitched, continuous honking sounds heard throughout the respiratory cycle but most prominent on inspiration. o Acute respiratory distress or foreign body in airway, Epiglottitis What does pleural friction rub sound like and what are some causes of this? o Rubbing together of inflamed pleural layers. o A high-pitched grating or rubbing sound that may be heard throughout the respiratory cycle.
o Loudest over lower lateral anterior surface. o Inflamed pleura- pleuritis
What does grunting sound like and what are some causes of this? o Retention of air in the lungs o High-pitched tubular sound heard on expiration o Emphysema
What is a barreled chest and what disease is associated with this finding? o Altered shape- 1:1 length to width ratio o COPD- chronically overinflated lungs so rib cage remains partially expanded
o What are normal and abnormal percussion findings during respiratory assessment? o Normal - Anterior chest: Resonance to second intercostal space (ICS) on left to 4th ICS on right. o Abnormal - Dullness: Tumors, fluid, pleural effusion, pneumonia, pulmonary edema Assess radial pulse and it is irregular what do you do o Listen to apical 1 minute Where is apical pulse o 5 th intercostal, midclavicular line
Where is dorsalis pedis pulse o Top of the foot For older client what happens with blood pressure o Increased systolic
Where to assess for cyanoiss in dark skin clients o Conjunctiva, oral MM, palms- minimal pigmentation What are expected heart sounds o Lub/dub, S1/S
What is swishing between S1/S2 sounds o Murmur Which patient should you see first- one with hypertension, one who is leaving for surgery, or one who has chest pain? o Chest pain
Can AP palpate pedal pulses for you o No
o Inspection- look for scars, assess respiratory rate, rhythm, depth, symmetry of chest movement, barrel chest, spinal deformities, accessory muscle use, and intact skin When auscultating the lungs, how long should you listen in each spot? o One full ventilation- inhale/exhale
What is the correct direction of lung sound auscultation? o Side to side to compare How do you determine if there is a pulse deficit? o One nurse counts the radial pulse while one nurse counts the apical pulse for one minute then subtract the difference How many lobes in right lung and left o Right 3 left 2 Who is at the greatest risk for developing pneumonia after having a procedure- a 32yr who just had abdominal surgery, an 82yr with syncope, an 18yr refusing to ambulate, or a 45yr with COPD? o 45yr with COPD- encourage patient to get pneumonvax as it is very difficult to recover from pneumonia with COPD Which pulse is never assessed bilaterally at the same time? o Carotid- will cut off brain blood flow
Post op patient encouraged to use what o Incentive spirometer- 5-10 hourly while awake o Cough and deep breathe
Post-op patient needs to do what to prevent pneumonia? o Sit up in chair for each meal o Oral care BID o Incentive spirometer- 5-10 hourly while awake o Cough and deep breathe
Where should post op patient eat breakfast o Up in a chair Which patients are the most susceptible to environmental pollution? o Patients with asthma
How can patients prevent COPD and what is the number 1 cause of this disease? o Stop smoking What should patients do to keep secretions thin o Hydration
What is the cause of high pitched monophonic crowing sound and patient has croup, how high of priority is this patient? o Stridor o Number 1- cause by an obstruction
Non-modifiable and modifiable risk factors for cardio dz o Over 65yr, family history o Smoking, lifestyle, obesity On right 2nd intercostal space sternal border listen to what o Aortic
On left 2nd intercostal space sternal border listen to what
o Tricuspid?
Where is Herbs point? o 3 rd intercostal space left stenal border On left 4nd intercostal space sternal border listen to what o
When you hear S1/S2 but the heart rate is 120 bpm what is this called? o Sinus tachycardia What is the term for short high pitched popping sounds over the lung bases that usually disappear after a few deep breaths and coughs? o Fine crackles- alveoli deflated right after waking up etc
Primary pacemaker of the heart is the o SA node
What is intrinsic rate of SA node o 60-
What is the term for the low-pitched snoring sound heard over the bases? o Ronchi
Bp 150/90 is what stage o Stage 2
135/ o Stage 1
Systolic < o Hypotension
>180/ o Hypertensive crisis
Signs of PAD o Hair loss on legs, leg pain after activity, ulceration on toes that do not bleed,
If you cant palpate a pulse what should you use? o Doppler
Where does gas exchange occur? o Alveoli
What is eupnea o Normal breathing
If patient had RR of 30 are they in respiratory distress? o Yes
If patient RR at 6 called what o Bradypnea, resp depression
How do you calculate cardiac output? o Stroke volume X heart rate
When assess for JVD what patient position in o 45 degrees
What is soft low pitched rushing sound? o Bruit
Essay- 4 things find with COPD patient o Barrell chest, chronic productive cough, tachypnea, clubbing, fatigue, accessory muscle use, prolonged expiration, SPO2 88-92% or lower
Health Assessment Exam 3 Study Guide
Course: Health Assessment (NURS 216)
University: Arizona College of Nursing
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