Maryville NURS 612 Exam 2 Questions with Complete Solutions

Maryville NURS 612 Exam 2 Questions with Complete Solutions inspect the chest - answerwithout clothes on; 1st assess shape and size; 2nd check for symmetry; 3rd thoracic landmarks; 4th color of skin; 5th check for supernumerary nipples; 6th superficial venous patterns; and 7th observe for rib prominence thoracic landmarks - answermidline trachea, costal angle, angle of ribs, intercostal spaces, suprasternal notch symmetry of chest - answerthoracic expansion at costal angle, w/o use of accessory muscles hx questions for cc of resp issue - answerWhat is the nature of your cough?; Do you produce any sputum?; Is your cough related to activity?; What position are you most comfortable in?; How many pillows do you sleep with at night?; Is your SOB related to activity? normal respirations - answerrate between 12 to 20/min; ratio of resp to heart beats= 1:4; pt should breathe easily, regularly w/o apparent distress; pattern should be even, not too shallow or too deep hypopnea - answerterm for abnormally shallow respirations tachypnea - answerterm for resp rate greater than 20, but consistent and may occur during hyperventilation; often a symptom of pain bradypnea - answerterm for resp rate less than 12; may indicate neurologic or electrolyte disturbances, infection, or conscious response to protect against the pain of pleurisy or other irritative pneumonia. Can also be 2/2 level of cardio fitness hyperventilation - answerterm for fast and deep, heavy respirations, can be caused by exercise, anxiety, and CNS and metabolic diseases hyperpnea - answerterm for abnormally deep respirations kussmaul respirations - answerdeep and mostly rapid respirations, used to describe resp effort of metabolic acidosis cheyne stokes respirations - answerregular breathing with intervals of apnea by crescendo decrescendo breathing; can be seen in sleeping pts, but mostly pts who are very ill, esp with brain damage biot respirations - answerirregular breathing that varies in depth and is interrupted irregularly by intervals of apnea; associated with severe and persistent increased intracranial pressure, resp compromise from drug poisoning, or brain damage at the medulla and generally equals poor prognosis peripheral areas related to respiratory assessment - answerobserve the lips and nails for cyanosis or pallor; lips for pursing; fingers for clubbing; and alae nasi for flaring pleural friction rub - answerdry, rubbing, or grating sound; palpable, coarse, grating vibration; usually on inspiration; caused by inflammation of the pleural surfaces; think feel of leather rubbing on leather thoracic expansion - answerstand behind patient and place thumbs along spinal process at level of 10th rib, with palms lightly in contact with the posterolateral surfaces; watch the thumbs during quiet and deep breathing; loss of symmetry = problem on either 1 or both sides. crepitus - answercrackly/crinkly sensation that can be palpated and heard, a gentle bubbly feeling; indicates air in the subcutaneous tissue from a rupture somewhere in the resp system, or infection with gas producing organism palpating the chest and trachea - answerpalpate the throracic muscles and skeleton; feeling for pulsations, areas of tenderness, bulges, depressions, masses, and unusual movement tactile fremitus - answerpalpable vibration of the chest wall that results from speech or other verbalizations. best felt posteriorly and laterally at the level of the bifurcation of the bronchi; have patient say "99" while you palpate with palmer surface of fingers or ulner aspect of the hand; use firm, light touch abnormal tactile fremitus - answerdecreased of absent fremitus may be caused by excess air in lungs or may indicate emphysema, pleural thickening, or effusion, massive pulm edema, or bronchial obstruction. Increased fremitus often coarser or rougher in feel, caused by presence of fluids or solid mass within the lungs. 7 characteristics of enlarged lymph nodes - answerlocation, size and shape, consistency, mobility, discreteness, tenderness, and warmth occipital lymph nodes - answerlymph nodes at the base of the skull postauricular lymph nodes - answerlymph nodes over the mastoid process, behind the ear preauricular lymph nodes - answerlymph nodes in front of the ear parotid and retropharyngeal lymph nodes - answerlymph nodes at the angle of the mandible (tonsillar) submandibular lymph nodes - answerlymph nodes halfway between the angle and tip of the mandible