1. Who established the first nursing philosophy based on Health maintenance and restoration?
Florence Nightingale
2.
Who developed the First organized program for training Nurses at the St. Thomas Hospital in
London? Florence Nightingale
3. Your patient is dying and unconscious due to ongoing kidney failure and made a request for no
resuscitation which means they want to die a natural death with no interference. On the other
hand, there family is refusing the request of the patient and wants nurses and doctors to
attempt resuscitation. As the Nurse directly responsible for this patient what should you do? As
An advocate you protect your patients human and legal rights and provide assistance in
asserting these rights. You must explain to the family that legally the patients personal wants
and needs come first and that it would be a violation of human rights to revive the patient.
4. Who was the founder of the red cross? Carla Barton
5. your role is to help patients maintain and regain health, manage disease and symptoms, and
attain a maximal level of Function and independence through the healing process, which
function of nursing are u conducting? Caregiving
6. What role of the skin? Protection, Sensation, Temperature Regulation, Excretion & Secretion
Produces and absorbs vitamin D in conjunction with
ultraviolet rays from sun
7.
You approach a patient and ask them if they would like a bed bath. They refuse because their
religions only allow them to bath once a month. What do you do?
You may choose to explain the consequences of not bathing, but cultural and personal beliefs
must be respect and protected at all times.
8. A patient informs you that they have dry, itchy skin that has been plaguing them for a long
period of time. What is their diagnosis? Diabetes Metellus or Medicines they have been taking
or even dehydration
9. A patient is in their late 60s and has had a history of contracting diseases and skin conditions.
While bathing the patient what should you be assessing? Condition of the skin (color, texture,
and turgor), presence of pigmented spots,
temperature, lesions, excoriations and/or abrasions
Fatigue, presence of pain and need for
analgesics ROM of the joints
10. A patient is 7 years old and needs a bed bath. When providing eye care what procedures and
special considerations must be outlaid?
Water, no soap
Clean inner to outer area
Special considerations
– Glasses
– Contact lenses
– Artificial eye
– Comatose patient
11. A Homeless Patients Hair, feet, and nails are extremely unkept. What must be done to resolve
this issue?
Hair care
– physician order to shampoo
– physician order to cut
• Shaving
– consider personal preferences
• Nails
– physician order to cut toenails
12. A 50-year-old patient is very susceptible to thrombophlebitis and
Embolism. What must be done to prevent this reoccurrence?
Antiembolism Stockings (TEDS)
(Elastic Stockings)
Side Note: Apply with patient lying down
• Do not massage legs
• Check heel position
• Loosen toes
• Remove q shift for about 30 min
• Launder prn / Re-use
13. What is an infection? Entry and multiplication of microorganism in
the tissues of a host, Invasion of body tissues by microorganisms.
14. What is medical asepsis?
Techniques or practices used to reduce or
prevent the spread of microorganism
15. What is Surgical Asepsis?
Techniques or practices that keep an area or object
free from all microorganisms
16. A patient enters the emergency room with a terrible infection on their right hand what kind of
infection is this?
Localized
17. A cancer has spread across the entire body of a patient infecting the majority of the cells in the
patient’s body what kind of infectious process is this? Systemic
18. A perfectly healthy Patient arrived in the hospital for a head-to-toe assessment but ended up
falling ill while in the care of multiple nurses. What can possibly be responsible for this
occurrence?
Nosocomial infections are infections associated with the delivery of health care services in a
health care facility
Common sites: respiratory tract, bloodstream, and wounds
Contributing factors: iatrogenic infections, compromised host, and hands of personnel
Common settings
19. A patient’s blood pressure has skyrocketed to 104 Fahrenheit which is considered well above
abnormal. What is the Normal Temperature for Average Adult? 96.8 to 100.4.
20. A patient recently suffered a brain injury during an activity, he has been experiencing a number
of signs and symptoms, one that involves rapid changes in his body temperature accompanied
by a fever. What is wrong with this patient?
The Hypothalamus has been damaged which has caused a rapid change in temperature in the
patient.
Hypothalamus controls body temp
21. What are the cardinal vital signs?.
1.Temperature
2. Pulse
3. Respiration
4. Blood Pressure
• Oxygen Saturation
22. What are the average and acceptable temperatures for adults?
Because of surface fluctuations
acceptable temp measurements are 96.8
to 100.4 for an adult
Average oral temp is 98.6
23. what are the roles of the anterior hypothalamus and the posterior hypothalamus?
Anterior hypothalamus controls heat loss
Posterior hypothalamus controls heat
production
24. A Patient is rushed into the hospital with a temperature of 103.2 and a fever. Soon after they
began sweating profusely with a high volume of water loss. What mechanism is causing this
reaction? Anterior hypothalamus senses and sends out
messages to the body to reduce heat by 1. Sweating
25. A mechanism to reduce heat is. Vasodilation - is the widening of blood vessels as a result of the
relaxation of the blood vessel's muscular walls. Vasodilation is a mechanism to enhance blood
flow to areas of the body that are lacking oxygen and/or nutrients.
26. How does the posterior hypothalamus increase production?
-Temp below set point, posterior
-hypothalamus senses and sends out
messages to increase heat production through Muscle shivering and
Vasoconstriction
27. What can be a cause for temperature variations? May be due to disease or trauma to:
• Hypothalamus (set point mechanism)
• Spinal cord (messenger system)
Diurnal (Circadian) Variations
• Occurs in repeated cycles, or 24-hour cycles
• Predictable fluctuations particularly related to
temperature and BP
• Temps are usually 1 to 2º F lower in the early
morning than in the late afternoon
• Peak temperatures occur in the late afternoon
between 4 and 7 PM
28. what is basal metabolism and what can increase basal metabolism?
- Basal metabolism is heat produced by the body at absolute rest
- Voluntary movements (exercise)
requires additional energy which raises
BMR. Heat production can increase up
to 50 times normal.
29. What are important terms?
Hyperpyrexia: Elevation of the body temperature above 106° F
Hyperthermia: elevated body temp
Hypothermia: decreased body temp
Malignant hyperthermia: a hereditary condition of uncontrolled heat production
30. what is remittent fever?
Fever spikes and falls without a return to
normal temperature levels
31. A young patient came into the hospital 12 hours ago with a fever, since his arrival he has
undergone multiple temperature checks that resulted in rapidly different temperatures. What is
the problem?
The patient is suffering from a remittent fever
32. what is a relapsing fever?
Periods of febrile episodes interspersed
with acceptable temperature values.
Febrile episodes and periods of
normothermia may be longer than 24
hours.
33. A 47-year-old African American male has been dealing with a fever for the last 4 days. He has
made complaints that every few hours his temperature would go from a perfectly normal rate
to one that was considerably higher or lower than normal. What is your initial diagnosis after a
few more in-depth questions? relapsing fever
34. A patient has complained of Malaise, muscle weakness, aching muscles. Drowsiness, delirium,
restlessness, convulsions along with an absence of chills what stage of fever is this?
Course) plateau
35. what is the onset stage of fever? Increased heart rate
• Increased respiratory rate
• Shivering
• Complaints of feeling cold
• Cold skin, goose bumps
• Cyanotic nail beds
• Cessation of sweating
36. what is the crisis (flushing stage) of a fever?
Crisis (Flushing) Stage
• Flushed warm skin
• Sweating
• Decreased shivering
• Possible dehydration
37. what are the classifications of hypothermia? Centigrade Fahrenheit
Mild 34 - 36° 93.2 - 96.8°
Moderate 30 - 34° 86.0-93.2°
Severe < 30° < 80.6°
38. what are clear signs of hypothermia?
Severe shivering (initially)
Feelings of cold/chills
Pale cool, clammy skin
Hypotension
Decreased urinary output
Lack of muscle coordination
Disorientation, drowsiness progressing to
Coma
39. Notes- Rectal temp usually 0.9º F higher than oral
temp
Axillary temp usually 0.9º F lower than oral
temp
40. Pro/cons of rectal temperature?
Advantages
- More reliable
- Disadvantages
-May lag behind core temp during rapid temp
-changes
-Requires positioning
-May be source of embarrassment and anxiety
- Risk of body fluid exposure
-Requires lubrication
-Contraindicated in newborns & other conditions
41. Pros and cons of oral temp?
Advantages
• Accessible – requires no position change
• Comfortable for client
• Provides accurate surface temperature
reading
• Indicates rapid change in core temperature
Cons of Oral Temp
Disadvantages • Affected by food and fluids, smoking, or
oxygen administration
• Contraindicated following oral surgery,
trauma, history of epilepsy, or shaking chills.
• Contraindicated in infants, small children, or
confused, unconscious, or uncooperative
clients
• Risk of body fluid exposure
42. Pro/cons of axillary temperature?
Advantages
• Safe and noninvasive
• Can be used in newborns and uncooperative clients
Disadvantages
• Long measurement time
• Requires continuous positioning
• Measurement lags behind core temp changes
• Requires exposure of thorax
43. What are Glass thermometers and functions?
Mercury in glass
Three types:
• Oral – long slender tip (blue color)
• Stubby – shorter/thicker tip (oral or rectal use)
• Rectal – blunt end (red color)
44. What are electronic thermometers ? Consist of a power unit and a probe,
connected by a cord.
Require a rechargeable battery powered
unit.
May be used to obtain oral, rectal,
axillary and tympanic temperature
measurements.
45. What are Pros/Cons of Electronic Type ?
Advantages:
• Plastic sheath unbreakable; ideal for children
• Quick readings
Disadvantages
• May be less accurate by axillary route
46. What are disposable thermometers ?
Disposable Thermometers
Thin strips of plastic with chemically
impregnated paper.
Tolerated particularly well with children
Two types:
• Oral or axillary
• Forehead or abdominal patch
What are Pros/Cons of Disposable Type ?
Advantages
• Inexpensive
• Provides continuous readings
• Safe and noninvasive
Disadvantages
• Lags behind other sites during temperature
changes, especially during hyperthermia
• Diaphoresis or sweat can impair adhesion
47. what is a pulse ?
Expansion can be felt as an
artery travels over a bony
prominence, called a pulse
48. what are key details of pulse rate ?
Varies with activity - Slowest at rest,
and in early AM
Rates: Pulsations per minute (bpm)
• Infant normal = 100 – 160 per minute
• Adult normal = 60 –100 per minute
Bradycardia (slow) = < 60
Tachycardia (fast) = > 100
49. factors contributing to tachycardia ?
Application of heat for prolonged periods
Decrease in BP
Elevated temperature
Any condition resulting in poor oxygenation of blood
Some medications
50. what are factors contributing to bradycardia ?
Person is at rest or has just awakened
Males have a slower pulse than females
People who are thin
Increasing age may be associated with a
slower pulse
Certain medications
51. what is the pulse deficit ? An inefficient contraction of the heart that fails to transmit a pulse
wave to the peripheral pulse site
To assess a pulse deficit the nurse and a colleague assess the radial and apical rates
simultaneously and then compare the rates
The difference between the apical and radial pulse rates is the pulse deficit
52. why is pulse strength important ?
Reflects the volume of blood ejected
against the arterial wall with each
contraction and the condition of the
arterial vascular system leading to the
pulse site
May be graded or described as strong,
weak, thready, or bounding
53. how to grade a pulse ?
0 - Absent pulse or not felt
1+ - Thready/Weak, not easily felt, slight
pressure occludes it
2+ - Normal
3+ - Bounding, stronger than normal e.g.
after increased activity
54. what is and where is the apical pulse ?
Referred to as the
“Central Pulse”
Located 4th to 5th
intercostal space at
left mid-clavicular
line
Counted by using a
stethoscope
To determine presence of pulse deficit (2
nurses count at same time, using same
watch)
55. what is the physiology of respiration ?
Movement of air in and out of lungs
Normal rate – 12 to 20
regulation of Carbon dioxide, & Oxygen levels
“Respiratory center” (located medulla oblongata and pons) regulates involuntary ventilation.
• Chemoreceptors
• Triggered by hydrogen, oxygen, carbon dioxide
Cerebral cortex allows voluntary ventilation
56. what is Normal Blood pressure ?
Normal
• systolic 100 to 119 mm Hg and
• diastolic 60 to 79 mmHg
57. what are the indications of hypertension ?
Most common alteration of BP
Often asymptomatic
Dx in adults: When 2 or more readings
on at least 2 subsequent visits indicates
diastolic pressure > or = 90 mm Hg
OR
systolic pressure > or = 140 mm Hg
58. how to classify hypertension ?
Pre-Hypertension – Systolic pressure
between 120-139 mm Hg or diastolic
pressure between 80-89 mm Hg
Stage 1 Hypertension (HTN) – Systolic
pressure between 140-159 mm Hg or
diastolic pressure between 90-99 mm Hg
Stage 2 HTN – Systolic pressure > 160 mm
Hg or diastolic pressure > 100 mm Hg
59. what is hypotension ?
Systolic pressure falls to 100 mm Hg or below
Symptoms: pallor, skin mottling, clamminess,
confusion, dizziness, chest pain, increased
HR, and decreased urine output
Hypotension is a life threatening event
60. what is Orthostatic (postural) Hypotension ?
Low blood pressure associated with
weakness or fainting when one rises to
an upright position (sitting or standing).
Results from peripheral vasodilation
without compensatory increase in CO
Corrected by lowering head of client
61. what are the kortokoff phases ?
Phase 1: Sharp thump or tap sound
(systolic pressure)
Phase 2: Blowing or whooshing sound
Phase 3: Softer thump than phase 1
Phase 4: Softer blowing sound that
fades
Phase 5: Silence (diastolic pressure)
62. what is palpating systolic BP ?
An indirect measurement of BP using
palpation for clients whose arterial
pulsations are too weak to create
Korotkoff sounds.
• Only systolic BP can be assessed via
palpation
63. what is oxygen saturation ?
Pulse oximeter
• Noninvasive device that measures arterial
blood oxygen saturation (SaO2)
Normal SaO2 is 95 to 100%
64. what is subjective data ?
Subjective Data
(client’s perception about
their own health problems)
Primary source includes information gathered
from the patient and the patient history
Secondary sources include information obtained
from family members, spouse, guardian etc.
65. what is objective data ?
Objective Data (observations or
measurements made by the data collector)
Physical Examination
Results of lab & diagnostic tests
66. what are the signs and symptoms ?
Signs - data that can be felt, heard, or
measured:
Enlarged liver
Clear lungs
Symptoms - what the client tells you:
Pain
Dizziness
Itching
67. what is an inspection ?
Refers to observing versus “looking at”
With obvious exceptions, the body is
symmetrical and can be compared to itself
Proper inspection requires:
Adequate lighting
Good exposure of area being inspected
68. A patient has arrived for a routine yearly head to toe assessment. What is the First few steps of
this assessment ?
Inspecting the patient and asking baseline questions to learn about your patient and their
medical history.
69. What is palpation?
Uses sense of touch.
Through this technique
might determine:
Hard versus Soft
Rough versus Smooth
Stillness versus Vibration
Warm versus Cold
70.What is percussion ?
Involves tapping of the body with the
fingertips to evaluate:
-Size
-Borders
-Consistency of body organs
- Fluid filled cavities
Two basic methods:
Direct – which involves tapping the body surface
directly
-Indirect
71.What is indirect percussion ? Indirect
Middle finger of the nondominant hand (pleximeter)
is placed firmly against the
body surface Tip of the middle finger of
the dominant hand (plexor)
strikes the base of the
distal joint of the
pleximeter.
72. Five types of percussions sound ?
Produces five types of sound:
------------ large air filled spaces, hollow organs
– stomach
Resonance --------- Air - lungs
Hyper resonance – Over inflation - gas, large intestines
Dullness -------------- Solid Organs - heart, liver
Flatness --------------- Muscles, bones
Each sound judged by: Intensity of pitch, Duration ,Quality
73. what is auscultation ?
Act of listening to sounds produced by the body
Some sounds heard with unassisted ear but most
heard with the use of a stethoscope
Generally done last except during the abdominal
examination
Listen in a quiet environment for the presence and
characteristics of sounds
Side note: NECK = Vascular - Carotid &
Breath Sounds
CHEST = Heart Sounds &
Breath Sounds
ABDOMEN = Vascular &
Bowel Sounds
74. Skin Color variations list
Flushing – reddened appearance of the skin
secondary to vascular changes in the dermis
Cyanosis – increased amount of
deoxygenated Hgb (associated w/ hypoxia)
Jaundice – yellow/orange color change as a
result of increased bilirubin in tissues
Pallor – (decrease in color) reduced amount
of oxyhemoglobin, may be due to anemia or
shock Ecchymosis – (bruise) collection of blood in
the tissues
Petechiae – small red ecchymotic changes
that occur due to capillary rupture in the
dermis.
Diaphoresis – when the entire skin is moist
(usually cool in temperature as well).
Edema – characterized by swelling, with taut
and shiny skin over the edematous area.
Turgor – the fullness or elasticity of the skin
and is usually assessed on the sternum or
under the clavicle.
75. What are the degrees of skin indentation ?
1+ (2 mm indentation, barely detectable)
2+ (4 mm indentation)
3+ (6 mm indentation)
4+ (8 mm indentation)
76. what is splinter hemorrhages ?
Splinter hemorrhages – red or brown linear
streaks in nail caused by trauma, bacterial
endocarditis
77. what is paronychia ?
inflammation of the skin due to
infection or trauma
78.what is Koilonychia ?
Koilonychia
(spoon nail)
Caused by iron
deficiency anemia,
syphilis, strong
detergents
79. what is clubbing ?
condition
in which the angle
between the nail and
the nail bed is 180° or
greater. May be
caused by a long term
lack of oxygen.
80. What are beau lines ? transverse
depressions in nails
due to systemic
illness such as severe
infection
81. how to assess the head and scalp ?
INSPECTION
-Normocephalic
-Symmetrical
PALPATION
-Skull smooth
-Non-tender
-No masses, depressions or lesions
82. how to inspect face during physical assessment ?
-Assess symmetry
- Facial features should be symmetrical
- Slight variations are common
- Movement
- (CN VII)-(Motor) ask patient to frown/smile
- SHAPE - Oval, round, or slightly
Square
- No edema or involuntary
Movements
Palpation
SENSATION (CN V) – (sensory)
compare sharp and dull
sensations on both sides of the
face.
83. How to assess the eyes ? VISUAL ACUITY (CN II) sensory
Snellen chart at 20 feet
20/20 normal vision
VISUAL FIELDS (CN II)
Remember to check each individual eye!!
84. what are the cardinal fields of gaze ?
Extraocular movement (EOM)
Move symmetrically & smoothly in the six fields
(CN III, IV, VI)
A little nystagmus is normal with extreme lateral
Gaze
85. You are performing a head to toe assessment on a patient with a history of poor skin elasticity, so u
emphasize the skin turgor part of the assessment. How do you test for this ?
To assess skin turgor,
a fold of skin on the
back of the forearm or
sternal area is
grasped with the
fingertips and
released. Normally
the skin should lift
and easily snap back
into resting position
86. what is a cause of a primary skin lesion? occur initially in response to
some change in the external environment
87. what is a cause of a secondary skin lesion ? do not appear initially but
result from modification such as trauma, infection, or chronicity of a primary lesion
88. where is the best place to assess turgor ?
Under the clavicle
89. why is scalp inspection so important ?
Dandruff- scalp conditions, pediculus capitis
Distribution- hormone disorders, hirsutism
Quantity - alopecia
Quality – dry, coarse
90. what can clubbing indicate ? Cardiovascular disease
91. what is a diaphragm used for ? High frequency sounds
92. what is bell used for ? Low frequency sounds
93. how do you properly assess edema ? Location, color, and temperature
94. how do you assess lesions ? distribution( Localized/generalized), Grouping( Clustered/linear), color,
texture, size and shape, and type.
95. what does it mean to be normocephalic ? Having a normal sized head
96. what are the cranial nerves ? olfactory, optic, oculomotor, trochlear, trigeminal, a? bducens, Facial,
acoustic, Glossophrayngeal, Vagus, Spinal accessory, hypoglossal( know all cranial nerves)
97. what is a normal assessment of pupil ? Deep black, round and equal diameter (3-7 mm)
98. what cranial nerve is used in pupil assessment ? Constrict (CN III) briskly to direct and consensual
light and accommodation (CN III). Insure that eyes are perrla
99. what are common eye abnormalities ? Myopia (nearsightedness) ,
Hyperopia (farsightedness),Glaucoma, cataract
100. how to assess ear function ? HEARING: Voice-Whisper or Watch Ticking Test
(CN VIII) Repeat words whispered from a distance of two feet
Use of watch to determine ticking distance, should be equal
`101. How to properly inspect the ear ?
Positioned centrally and in proportion to head
Top of ear positioned at height of outer canthus of eye
102. How to assess the ear ?
INSPECTION
Shape can vary greatly
Located symmetrically and midline
No bleeding, swelling, lesions, or masses
SMELL (CN I) remember to check each individual nostril
103. what are abnormalities of the naso oro-phyranx? Acetone/fruity breath = DKA
Ammonia = end stage renal disease
Bleeding gums
Caries
Infection
Dehydration
THROAT Tonsils large and red
Exudate
104. How to inspect neck ? Full range of motion, trachea midline, and check for jvd and check no bruits
105. what are the various cranial nerves ?
1.Cn I- Olfactory- Test for smell. Ask patient for any difficulties with smelling. Heavy smokers and
older patients lose their sensitivity to smell.
2. CNII-Optic- Test for acuity Ophthalmic – test for visual acuity. Inspect globe of eyes for foreign
bodies,
inflammation, or cataracts. Ask patients regarding use of eyeglasses.
3. Oculomotor – test for extraocular eye movement/pupillary constriction/elevation of
eyelid – test 6 cardinal fields of gaze.
Direct/consensual response - with penlight held
from temporal area, check pupil response to eye, as well as response to opposite eye.
Accommodation – pupils focus on near and far objects. Ask patient to look away at a
distant object then look at object 6 inches away. Pupil will dilate when looking away and
constrict when looking at close range. Lens shape will change. PERRLA
4. Trochlear – test for extraocular eye movement/ test 6 cardinal fields of gaze.
5. Trigeminal – test for motor division. Mastication move jaw side to side, open mouth
widely. Facial sensation (sharp, dull).
6. Abducens – test for lateral eye movement – test 6 cardinal fields of gaze.
7. Facial – test for facial expressions. Smile, frown, and raise eyebrows, forehead, and puff
out cheeks. Taste anterior of tongue, salivation.
8. Acoustic – test for cochlear and vestibular. Cochlear nerve permits hearing. Whisper in
patient’s ears/rustle hair/ vestibular nerve maintains equilibrium.
9. Glossopharyngeal – test for gag reflex/uvula/swallow. Ask patient to say ah! Check
position of uvula and palate. Ask patient to swallow.
10. Vagus – test for cough/speak. Weak cough/speech – signs of brain stem trauma, tumors.
11. Spinal Accessory – test for sternocleidomastoid muscle innervation. Ask patient to shrug
shoulders, push against resistance, and tilt head side to side.
12. Hypoglossal – test for tongue movement. Ask patient to open wide, stick out tongue,
move side to side. Say D, L, N, I
106. what is an abnormality of the throat ? Tonsils large and red
Exudate
107. What is an abnormality of the mouth ?
Acetone/fruity breath = DKA
Ammonia = end stage renal disease
Bleeding gums
Caries
Infection
Dehydration
108. what are abnormalities of the head and neck ?
Hydrocephalus is the buildup of too much cerebrospinal fluid in the brain . Normally, this fluid
cushions your brain.
Acromegaly - A rare condition which results from excessive production of growth hormone by the
pituitary gland. This causes enlarged bones in face, feet and hands.
Bell’s palsy - A condition that causes temporary weakness or paralysis of the muscles in the face. It
causes paralysis on one side of the face, drooping face, headache, loss of taste, increased sensitivity to
sound, dry eye and dry mouth.
Down’s syndrome - A genetic disorder associated with physical growth delays, characteristic facial
features and mild to moderate developmental and intellectual disability. It is caused by the presence
of full or partial extra copy of chromosome 21.
Goiter - An abnormal enlargement of the thyroid gland that causes coughing, difficulty breathing,
hoarseness, and difficulty swallowing.
Bruit - the abnormal sound generated by turbulent flow of blood in an artery due to either an area of
partial obstruction or a localized high rate of blood flow through an unobstructed artery.
109. what is the shape of thorax ? AP diameter, transverse diameter 1:2
110. what indicates symmetry of chest wall ?
Shoulders at same height ------------Scapula same height
No masses
111. what is the tracheal position ?
Midline
Suprasternal notch
112. what to look for when assessing intercoastal spaces ?
Absence of retraction
No bulging of ICS
113. what is the normal rate and depth of respiration ?
Eupnea = 12 to 20 breaths per minute
DEPTH
Inspiration non-exaggerated
Effortless
114. What are percussion sounds of the thorax ?
Lungs = Resonant sound
Diaphragm = Dull sound
Ribs = Flat sound
115. Normal breath sounds of thorax ?
-Bronchial
-Bronchovesicular
-Vesicular
116. what are vesicular sounds?
Heard over most of lung fields
Low-pitched
Low-intensity, soft, short expiratory phase
Heard over healthy lung tissue of the
1. Lesser bronchi
2. Bronchioles
3. Lobes
117. what are bronco-vesicular sounds ?
Heard over major bronchi and over upper
right posterior lung field
Typically moderate in pitch & intensity
Expirations equals inspiration
118. what are bronchial sounds ?
Heard only over the trachea
High pitched
Loud, long expirations
119. when assessing sputum what is being looked for ?
Amount
Color
Odor
Consistency
120. what is sputum ?
a mixture of saliva and mucus coughed up from the respiratory tract
121. what are key abnormalities of the thoracic region ?
-Bulging or retraction of ICS
-Accessory muscle use
-Tachypnea (> 20 breaths per minute)
-Bradypnea (< 12 breaths per minute)
-Apnea (absence of breath)
-Abnormal respirations eg. Chayne-Stokes
122. what is the color of sputum ? Color: yellow, green, rust, blood tinged, black, pink
123. what are adventitious lung sounds ?
Crackles (Rales)
Rhonchi
Wheeze
Pleural friction rub
Stridor
Bronchovesicular or bronchial breath sounds heard
over peripheral lung tissue
124. what is the location of Aortic area ?
Second ICS to right of sternum
pulsation should be seen
125. what is the location of the pulmonic area ?
Second ICS to left of sternum
No pulsation should be seen
126. what is the location of the tricuspid area ?
Fourth ICS to left of sternum
No pulsation should be seen
127. what is the location of the mitral area ?
Fifth ICS to left of midclavicular line
50% of population with visible pulsation called “point of
maximal impulse” (PMI)
128. where should apical pulse be felt ?
Apical impulse felt at mitral area
129. what are the auscultation of the cardiac system ?
-Aortic area
S2
Closure of valves
Corresponds to “dub”
-Pulmonic area
S2
Softer here than at aortic rea
- Tricuspid area
S1
Softer here than in mitral area
- Mitral area
S1
Heard loudest here
Corresponds to the “lub
130. Steps of Jvd inspection ? Estimates central venous pressure
-Normal 0 to 9 cm
-HOB at 45 degrees: venous distention noted 1 - 2 cm
above sternal angle
-HOB at 90 degrees: absent JVD
131. when palpating arterial pulses you are assessing ?
-Rate, rhythm, quality, symmetry
- Temporal, carotid, brachial, radial, femoral, popliteal,
posterior tibial, dorsalis pedis
132. what are the pulses of the upper extremity ?
Radial – Along the radial side of the forearm, at the wrist.
Ulnar – Opposite side of the wrist
Brachial – Groove between the biceps and triceps at the
antecubital fossa
133. what are the pulses of the lower extremity ?
Femoral – Between the symphysis pubis and the
anterosuperior iliac spine
Popliteal – Behind the knee
Dorsalis Pedis – In the groove between the great toe and
the first toe
Posterior Tibial - Inner side of the ankle
134. when inspecting and palpating veins their must be no…
No varicosities
No peripheral edema
No phlebitis
135. what are cardiac abnormalities ?
Extra heart sounds (S3 or S4)
Heart murmurs
Presence of JVD - indicates increased CVP i
Bruits
Calf pain (+) Homan’s sign
136. where is abdominal cavity located ?
Located between the diaphragm and the
symphysis pubis
137. what is paradoxical respiration ? The presence of paradoxical breathing points to various types of
respiratory distress or respiratory failure.
138. The umbilicus should be ?
-Depressed
- Beneath abdominal surface
139. what sound are heard from bowels ?
Bowel sounds
Intermittent gurgling sounds in all four quadrants
High pitched
5 to 30 per minute
Always hear in right lower quadrant (RLQ)
140. what are the abdominal vascular sounds ?
Vascular sounds – aorta, renal, iliac, femoral
Bell and diaphragm
No bruits heard
141. what are the bladder levels ?
Empty not palpable
Moderately full -- smooth and round, above
the symphysis pubis
Full bladder -- above symphysis pubis, may
be close to umbilicus
142. what are the abdominal abnormalities ?
-Strong abdominal pulsation
Aneurysm
-Hernias
-Absent bowel sounds
Obstruction
-Abdominal bruit
Aneurysm
-Dullness where tympany should be heard:
Tumor
Mass
Ascites
143. when assessed how should joints be performing ?
Area free of edema, pain, tenderness, or warmth
Moves through normal range of motion (ROM)
144. what causes limited movement ?
Parkinson’s disease
Arthritis
Pathological fractures
Atrophy of muscles
145. what are involuntary movements ?
Spasms- sudden, violent, involuntary muscle contraction
Tetany- sharp flexion of wrist & ankle joints
Tic- involuntary, compulsive, rapid, repetitive movement
Dystonia- dyskinetic movements
146. how to inspect male genitals ?
Testicular self-exam
Drainage or discharge
No lesions
147. when assessing female genitals you must ask and palpate for ….
Last menstrual period
Vaginal discharge
Gravida (number of
pregnancies)
Parity (number of births)
Type of birth control
Genital lesions