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NUR2222 Exam 1 Latest Update
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NUR2222 Exam 1 Latest Update ...
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NUR2222 Exam 1 Latest Updatenose examination inspection - Answer patency, inflammation, deformities, symmetry,
and discharge. mucous membrane pink and moist, no exudate bleeding, edema. Nasal
septum for deviation, perforations, bleedings. Inspect turbinates for polyps, abnormal
fingerlike projections of swollen nasal mucosa.
Mouth and pharynx inspection - Answer inspect the interior of the mouth for color,
lesions, masses, gum retraction, bleeding, and poor dentition. Inspect the tongue for
symmetry and lesions. Pharynx should be smooth. stimulate gag reflex.
neck inspection - Answer symmetry and tender areas.
neck palpation - Answer palpate lymph nodes from ears, to the nodes at the base of the
skull and then to those located under the angles of the mandible to the midline.
thorax and lungs inspection - Answer
AP ratio 1:2 - Answer an increase in AP diameter.
pectus carinatum - Answer pigeon chest
pectus excavatum - Answer a chest that is hollowed out
Inspiration: Expiration ratio - Answer should be 1:2
clubbing - Answer bulbous enlargement of distal phalanges of fingers and toes that
occurs with chronic cyanotic heart and lung conditions
subjective medications questions for short-term bronchodilators - Answer any overuse
subjective questions data for respiratory assessment - Answer thorough med hx, Px &
OTC. Use of ACE inhibitors since cough is a common s/e. If using O2, document use.
dry hacking cough - Answer airway irritation or obstruction
harsh, barky cough suggests - Answer upper airway obstruction from inhibited vocal
cord movement r/t subglottic edema.
loose-sounding cough - Answer secretions
acute vs chronic cough - Answer chronic longer than 3 weeks.
COPD sputum - Answer exhibit clear, whitish, or slightly yellow sputum, especially in the
morning on rising.
thick, thin, frothy and pink tinged sputum - Answer dehydration, postnasal drip, or sinus
drainage, or possible pulmonary edema.
massive hemoptysis - Answer More than 600 ml of blood expectorated over 24 hours
,most important risk factor for COPD and lung cancer - Answer pack years,
assess if the pt for immunizations - Answer influenza and pneumococcal pneumonia
vaccines
respiratory questions r/t travel - Answer TB includes China, India, former soviet
republics, latin america, developing countries. homeless, injection drug users, ppl with
HIV.
weight loss r/t respiratory assessment - Answer fatigue from hypoxemia, increased
work of breathing, lung hyperinflation-feeling full quickly.
anorexia, weight loss, and chronic malnutrition are common in pts with - Answer COPD,
lung cancer, TB, and chronic severe infection.
dyspnea can also be the cause of limited - Answer mobility, which can cause
constipation. especially women, may be troubled w/ urinary incontinence during
paroxysms of coughing.
activity-exercise pattern for respiratory assessment - Answer determine if the patient's
activity is limited by dyspnea at rest. ADLs.
sleep-rest-pattern respiratory assessment - Answer does the patient need to wake up
because of pulmonary problems. COPD/awake in the night w/ chest tightness, wheezing,
coughing- need for med change. too much weight interfere with normal ventilation,
sleep apnea. Morbidly obese hypoventiliate.
sleep apnea manifestations - Answer snoring, insomnia, abrupt awakenings, daytime
drowsiness, and early morning headaches.
night sweats can be a sign of - Answer TB
cognitive-perceptual pattern respiratory assessment - Answer hypoxia can neurologic
symptoms. ask pt about apprehension, restlessness, irritability, memory changes which
can indicate inadequate cerebral oxygenation. can impair teaching so include caregiver
to provide reinforcement. assess cognitive ability to cooperate w/ tx.
Self-Perception-Self-Concept Pattern - Answer Describes patient's self-concept pattern
and perceptions of self (e.g., self-concept/worth, emotional patterns, body image) nasal
cannula, O2 equipment. Barrel chest, clubbed fingers, pursed-lip breathing, frequent
expectoration of sputum or throat clearing.
role-relationship pattern respiratory pattern - Answer work hazards like fumes, toxins,
asbestos, coal, fibers, silica. Woodworking, pottery, animals.
sexuality-reproductive pattern respiratory - Answer good pulmonary hygiene(
bronchodilators, coughing, and deep breathing before intimacy. O2 during intercourse.
coping stress tolerance pattern respiratory - Answer dyspnea causes anxiety which can
,exacerbate dyspnea.
increased fremitus - Answer occurs with compression or consolidation of lung tissue.
Pneumonia, lung tumors, thick bronchial secretions, and above a pleural effusion.
decreased fremitus - Answer occurs with obstructed bronchus, pleural effusion or
thickening, pneumothorax, or emphysema
auscultation findings to be reported immediately - Answer absent air entry
bronchial sounds - Answer those heard over the trachea; high in pitch and intensity,
with expiration being longer than inspiration (3:2) listen over trachea in neck
bronchovesicular sounds - Answer normal breath sounds heard over the upper anterior
chest and intercostal area. 1:1 ratio.
vesicular sounds - Answer sound resulting from air passing through small bronchi and
alveoli 3:1 ratio.
subjective for respiratory - Answer dyspnea, wheezing, sputum production, pain w/
breathing, cough
objective diagnostic respiratory - Answer ABGs, CX, Hct, Hgb,
Objective physical exam respiratory - Answer Respiration: rate, quality, pattern. Inspect
skin, nails, neck, chest wall. Palpate chest and back for masses. Auscultate for sounds.
normal nose assessment - Answer • Symmetric with no deformities
• Nasal mucosa pink, moist with no edema, exudate, blood, or polyps
• Nasal septum straight (slight nasal deviation possible). Nares patent bilaterally
, oral mucosa normal - Answer • Light pink, moist, no exudate or ulcerations
pharynx normal findings - Answer smooth, moist, pink,
neck normal - Answer trachea midline
chest normal assessment - Answer AP diameter 1:2. resp: 12-20 b/min. breath sounds
vesicular w/o crackles or wheezes. excursion equal bilaterally w/ no increase in tactile
fremitus.
pursed-lip breathing etiology and significance - Answer COPD, asthma. Suggests ↑
breathlessness
Strategy taught to slow expiration, ↓ dyspnea
Tripod breathing etiology and significance - Answer COPD, asthma exacerbation,
pulmonary edema
Indicates moderate to severe respiratory distress
Accessory muscle use. Intercostal retractions etiology and significance lung
assessment - Answer COPD, asthma exacerbation, secretion retention
Indicates severe respiratory distress/failure, hypoxemia
splinting lung assessment etiology and significance - Answer Thoracic or abdominal
incision, chest trauma, pleurisy
increased AP diameter - Answer COPD, asthma, cystic fibrosis, lung hyperinflation,
advanced age
tachypnea etiology and significance - Answer Fever, anxiety, hypoxemia, restrictive
lung disease
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