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definitions Focus your studying with a path Get faster at matching terms BRONCHIAL (TRACHEAL) - High
pitch, Loud tone, Inspiration < expiration, Harsh, hollow tubular, Trachea and larynx BRONCHIAL (TRACHEAL) - Trachea and larynx, High, Loud, Inspiration < expiration, Harsh, hollow tubular. Sets found in the same folderRestlessness, tachypnea, tachycardia, and diaphoresis Rationale: With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation. A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation? In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? a. Family history, hypertension, stress, and age b. Personality type, high cholesterol, diabetes, and smoking c. Smoking, hypertension, obesity, diabetes, and high cholesterol d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol The nurse is assessing a client's neck ROM. The nurse would correctly expect the client to be able to perform which movements with the neck? A. Flexion, hyperextension, rotation and lateral bending The nurse is charting on a client's eye assessment and notes PERRLA. What does this stand for? A. Pupils Equal, Rigid, React to Light, and Accessible The nurse is assessing a client's neck ROM (Range of Motion). The nurse would correctly expect the client to be able to perform which movements with the neck? A. Eversion, pronation, external rotation, hyperextension
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Terms in this set (109)Increased tactile fremitus would be evident in an individual who has which of the following conditions? Pneumonia Fremitus is a palpable vibration. Increased fremitus occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). Which of the following voice sounds would be a normal finding? The "eeeee" sound is clear and sounds like "eeeee." The gradual loss of intra-alveolar septa and a decreased number of alveoli in the lungs of older adults cause decreased surface area for gas exchange. Stridor is a high-pitched, inspiratory crowing sound commonly associated with upper airway obstruction. Stridor is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body. Percussion of the chest is helpful only in identifying surface alterations of lung tissue. Percussion detects only the outer 5 to 7 cm of tissue; it does not penetrate to reveal any change in density deeper than that.An abnormal finding must be 2 to 3 cm wide to yield an abnormal percussion note. Percussion findings (resonant notes) may be modified by a muscular chest wall of an athlete or subcutaneous tissue of an obese person. Resonance is a low-pitched, clear, hollow sound that predominates with percussion of healthy lung tissue. Which of the following is a clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD)? Prolonged expiration When auscultating lung sounds, it is important for the nurse to do which of the following? Tell the patient to stop the assessment if he/she begins to feel dizzy. It's important to instruct the patient to let you know if they are beginning to feel dizzy during auscultation assessment as this is an early sign of hyperventilating. Must listen to full inspiration and expiration cycle and do not move quickly through the assessment as this will lead to dizziness, hyperventilation, and could cause the patient to faint. Lung sounds must be compared in each spot between both lungs. Listening to all fields in one lung prevents comparison. Anterior auscultation includes 5 spots on each side. Posterior auscultation includes 9 spots on each side. Inspiration is primarily facilitated by which of the following muscles? Diaphragm and intercostal An increase in the transverse diameter of the chest cage in a pregnant woman is due to a(n) increase in estrogen. When preparing to complete thorax and lung objective assessment of an infant or child, the nurse should do which of the following? -Allow the caregiver to hold the infant. -If infant is sleeping, perform auscultation before doing any other objective assessments. Describe the most important points about the health history for the respiratory system. • Do you have a cough? When did it start? Cough up any phlegm or sputum? Describe the pleura and its function. are thin, slippery membranes that form an envelope between the lungs and the chest wall. The visceral pleura lines the outside of the lungs, dipping down into the fissures; the parietal pleura lines the inside of the chest wall and diaphragm and is continuous with the visceral pleura. List the structures that compose the respiratory dead space. The trachea and bronchi constitute the respiratory dead space, or space that is filled with air but is not available for gaseous exchange. ... ... List the elements included in the inspection of the respiratory system. Inspection of the posterior chest (thoracic cage): Discuss the significance of a barrel chest. occurs when the anteroposterior diameter is equal to the transverse diameter. Normally the
anteroposterior diameter is less than the transverse diameter. In addition, the ribs are horizontal and the chest appears as if held in continuous inspiration. List and describe 3 types of normal breath sounds. descriptions of bronchial, bronchovesicular, and vesicular breath sounds. Define 2 types of adventitious breath sounds. Discontinuous sounds (fine, coarse crackles, atelectatic crackles, pleural friction rub) The manubriosternal angle is also called ____________________. Why is it a useful landmark? sternal angle or angle of Louis How many degrees is the normal costal angle? ___________________ 90 degree or less When comparing the anteroposterior diameter of the chest with the transverse diameter, what is the expected ratio? What is the significance of this? The expected ratio is 1:2 to 5:7. What is the tripod position? when the person leans forward with arms braced against the knees, a chair, or the bed. This gives the person leverage so that the rectus abdominis, intercostals, and accessory neck muscles all can aid in expiration.
List 3 factors that affect the normal intensity of tactile fremitus (1) Relative location of the bronchi to the chest wall. During percussion, which sound would you expect to predominate over normal lung tissue? Resonance is the predominant sound in healthy lung tissue. List 5 factors that can cause extraneous noise during auscultation (1) Examiner's breathing on the stethoscope tubing. Describe the 3 types of normal breath sounds. descriptions of bronchial, bronchovesicular, and vesicular breath sounds. The manubriosternal angle is: a. The articulation of the manubrium and the body of the sternum. a-The articulation of the manubrium and the body of the sternum. Select the correct description of the left lung. b. Narrower than the right lung with two lobes You assess a patient who reports a cough. The
characteristic timing of the cough of chronic bronchitis is described as: b. Productive cough for at least 3 months of the year for 2 consecutive years. Which of the
following assessments best confirms symmetric chest expansion? a. Placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch a small fold of skin between the thumbs You are auscultating breath sounds on a patient. Which of the following best describes how to proceed? b. Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side-to-side comparisons. Select the best description of bronchovesicular breath sounds. b. Moderate-pitched, inspiration equal to expiration After examining a patient, you note: fever, increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with: d. Lobar pneumonia. On examining a patient's nails,
you note that the angle of the nail base is >160 degrees and that the nail base feels spongy to palpation. These findings are consistent with: c. Congenital heart disease and COPD. On auscultating a patient, you note a coarse, low-pitched sound during both inspiration
and expiration. This patient reports pain with breathing. These findings are consistent with: d. Pleural friction rub. To use the technique of egophony, ask the patient to: b. Say "eeeeee" each time the stethoscope is moved. When examining for tactile fremitus, it is important to: c. Palpate the chest symmetrically. Pulse oximetry measures: a. Arterial oxygen saturation of hemoglobin. A pleural friction rub is best detected by: c. Auscultation. A patient has a barrel-shaped chest, characterized by: a. Equal anteroposterior transverse diameter and ribs being horizontal. Alveoli Terminal air sacs that constitute the gas exchange surface of the lungs. Angle of Louis manubriosternal angle, the articulation of the manubrium and body of the sternum, continuous with the second rib apnea absence of breathing Asthma abnormal respiratory condition associated with allergic hypersensitivity to certain inhaled allergens, characterized by inflammation, bronchospasm, wheezing and dyspnea atelectasis collapsed lung; incomplete expansion of alveoli bradypnea an abnormally slow rate of respiration usually of less than 10 breaths per minute Bronchioles Airways in the lungs that lead from the bronchi to the alveoli. bronchitis inflammation of the bronchi with partial obstruction of bronchi due to excessive mucus secretion Bronchonphony the spoken voice sound heard through the stethoscope, which sounds soft, muffled and indistinctive over normal lung tissue bronchovascular normal breath sound heard over major bronchi, characterized by moderate pitch and an equal duration of inspiration and expiration chronic obstructive pulmonary disease (COPD) permanent, destructive pulmonary disorder that is a combination of chronic bronchitis and emphysema Cilia hairlike cells lining the tracheobronchial tree Consolidation the solidification of portions of lung tissue as it fills up with infectious exudate, as in pneumonia crackles (rales) abnormal, discontinuous, adventitious lung sounds heard on inspiration Crepitus coarse, crackling sensation palpable over the skin when air abnormally escapes from the lung and enters the subcutaneous tissue dead space passageways that transport air but are not available for gaseous exchange (e.g., trachea, bronchi) Dyspnea difficult or labored breathing Emphysema chronic obstructive pulmonary disease characterized by enlargement of alveoli distal to terminal bronchioles fissure the narrow crack dividing the lobes of the lungs fremitus a palpable vibration from the spoken voice felt over the chest wall friction rub a coarse, grating, adventitious lung sound heard when the pleurae are inflamed hypercapnia increased amount of carbon dioxide in the blood Hyperventilation increased rate and depth of breathing Hypoxia Low oxygen saturation of the body, not enough oxygen in the blood intercostal space space between the ribs Kussmaul respirations type of hyperventilation that occurs with diabetic ketoacidosis orthopnea ability to breathe only in an upright position paroxysmal nocturnal dyspnea sudden awakening from sleeping with shortness of breath pecussion striking over the chest wall with short, sharp blows of the fingers to determine the size and density of the underlying organ Rhonchi low-pitched, musical, snoring, adventitious lung sounds caused by airflow obstruction from secretions
Tachypnea rapid, shallow breathing Vesicular refers to soft, low-pitched, normal breath sounds heard over peripheral lung fields wheeze high-pitched, musical, squeaking adventitious lung sound xyphoid process sword like pointy process- cartilage when young. turns to bone as we age This tool is used to check air and bone conduction hearing loss or to make sure your musical instrument is at the proper pitch... tuning fork when performing this test your head is 30-60 cm away from the client and it is imperative they do not see your lips when you say several two syllable words... Whisper test This type of infection cause fever, pain and even purulent drainage if the eardrum is ruptured... otitis media this condition is when a newborn's tongue is attached too close to the floor of the mouth. Contrary to its name, it is not the connection from the leg to the foot. Ankyloglossia this assessment finding manifest as a central gray opacity and negatively affects vision Nuclear cataract The congenital defect is displayed when the lip and or palate do not properly close Cleft lip or cleft palate decreased overall pupil size in the elderly is common but this is an unexpected and abnormally pupillary finding in this population Unequal pupillary constriction this patient behavior is a sign of hemorrhage following a tonsillectomy frequent swallowing These are classic signs of allergies clear nasal drainage, eyelid creasing and transverse line across the the bridge of the clients nose the result of cranial nerve III damage is ptosis, which manifest in this specific way... the drooping of the upper lid this is an infected hair follicle that is painful furuncle an inherited recessive X-linked trait affecting about 8% of white males and 4% of african american males and is checked between age 4-8 is.... colorblindess this finding in newborn related to weak eye muscle may concern new parents but it will usually go away after three months without intervention eye crossing unlike otitis media, this infection may cause erythema and edema otitis externa this is a condition in which the eyes are not aligned together when looking at an object and is caused by the lack of eye muscle strength.. strabismus this is the procedure used for assisting pupillary light reflex shining a penlight across the pupil from the side precuts excavatum a chest that is hollowed out barrel chest anteroposterior = transverse diameter suprasternal notch Hollow, U-shaped depression just above the sterum, in between clavicles Sternal Angle (Angle of Louis) the articulation of the manubrium and the body of the sternum shortness of breath and pleural pain commonly after having anesthesia, opioids or pain medicine aletectasis stridor, wheezing and sometimes and ear infection bronchitis symptoms include low grade fever, night sweats and weight loss, blood in sputum and may be blood streaked turburculosis pharyngitis, intermittent fever and eye discharge Common cold or rhinoritis nasal discharge, headache and cough influenza these lung sounds are high pitched, musical squeaking sounds that sound polyphonic (multiple notes as in a musical chord) and predominate in expiration but may occur in both expiration and inspiration high pitch wheezes this lung sound has a very superficial sound that is both coarse and low pitch it has a breathing grading quality of tow pieces of leather are rubbing together pleural friction rub this lung sound is loud with low pitch bubbling and gurgling sounds. this is in early inspiration and may be present in expiration. crackles high pitch monophonic inspiratory crowning sounds that are louder in the neck than over the chest wall stridor stridor Harsh or high-pitched respiratory sound, caused by an obstruction of the air passages the lung sounds are continuous rumbling snoring or rattling sounds resulting from fluid or mucus Rhonchi rhonchi (singular: rhonchus) loud rumbling sounds heard on auscultation of bronchi obstructed by sputum sighs breath of deep inspiration and prolonged expiration this respiratory pattern unusually deep but regular breaths kussmaul's respiration Kussmaul respirations very deep, labored breathing (usually associated with diabetic acidosis and renal failure) Sets with similar termsJarvis Chapter 18 Thorax and Lungs22 terms aev0110 Assessments Ch 18 Lungs and Chest77 terms Amoni83 Chapter 18: Thorax and Lungs (Health Ass…53 terms CaseyY07 Thorax and lungs45 terms Cupcake75 Sets found in the same folderHealth Assessment Exam 1131 terms Kepmuving NR 302 Health Assessment- Chapter 20123 terms vikki_her NR 302 jeopardy Q's133 terms carly_aselage Final Exam NR 302104 terms kmcgill6 Other sets by this creatorNR 293- Pharmacology Vocabulary109 terms vikki_her NR 304 - Chapter 23 &24385 terms vikki_her NR 304 Exam 1- Chapters 21 & Chapters 22205 terms vikki_her NR 224 Fundamentals- Chapter 276 terms vikki_her Other Quizlet setsMWV30 terms Oguzhan46 Sales and Leases Quiz 150 terms Baylie_Moravec Research Methods Exam 249 terms kailyn_wright Related questionsQUESTION Which reason explains why, according to Weberian analysis, an automobile assembly plant is most likely to be located at an intermediate location approximately at D? 15 answers QUESTION What are three purposes for the boost pumps in an aircraft fuel system 15 answers QUESTION Where do the IV and DV go on a graph? 15 answers QUESTION True or False: Contact metamorphism produces rocks with foliated texture. 3 answers |
When Auscultating lung sounds it is important for the nurse to do which of the following quizlet?
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