Maryville NURS 612 Exam 2 NEWEST WITH ACTUAL QUESTIONS AND DETAILED
VERIFIED SOLUTIONS (A+ Graded 100% Pass)
Inspect chest - Respond with no clothing on; 1st shape and size; 2nd symmetry; 3rd
thoracic landmarks; 4th color of skin; 5th supernumerary nipples; 6th superficial venous
patterns; and 7th watch for prominent ribs
symmetry of chest - Respond thoracic expansion at costal angle, w/o accessory muscles
hx questions for cc of resp issue - Answer What 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 - Anwer rate 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 - Anwer term for abnormally shallow respirations
tachypnea - Anwer term for resp rate greater than 20, but consistent and may occur
during hyperventilation; often a symptom of pain
bradypnea-Answer term 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-Ans term for fast and deep, heavy respirations, can be caused by
exercise, anxiety, and CNS and metabolic diseases
hyperpnea-Ans term for abnormally deep respirations
kussmaul respirations-Answer deep and mostly rapid respirations, used to describe
resp effort of metabolic acidosis
cheyne stokes respirations-Answer regular breathing with intervals of apnea by
crescendo decrescendo breathing; can be seen in sleeping pts, but mostly pts who are
very ill, esp w/ brain damage
biot respirations - Answer a type of respiration marked by irregular respirations with
alternating depth and interrupted by periods of apnea; caused by severe and sustained
increased intracranial pressure, resp failure due to poisoning, or brainstem damage at
the medulla and is usually indicative of bad prognosis
peripheral areas related to respiratory assessment - Answer lips and nails- for cyanosis
or pallor; lips-for pursing; fingers-for clubbing; and alae nasi-for flaring
pleural friction rub dry, rubbing, or grating sound; palpable, coarse, grating vibration;
usually on inspiration; cause inflammation of the pleura; think feel of leather rubbing on
leather
thoracic expansion-Answer stand 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 - grating/crackly sensation that can be palpated and heard, a soft bubbly
feeling; indicates air in the subcutaneous tissue from a rupture somewhere in the resp
system, or infection w/ gas producing organism
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