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Nur 634- Exam #2 Questions With
Correct Detailed Answers
Which lobes of the lung will be heard anteriorly? - ANSWER- - Right Upper Lung
- Right Middle Lung
- Right Lower Lung
- Left Upper Lung
- Left Lower Lung Which lobes of the lung will be heard posteriorly? - ANSWER- - Right Upper Lung
- Right Lower Lung
- Left Upper Lung
- Left Lower Lung Which lobes of the lung will be heard laterally - right? - ANSWER- - Right Upper Lung
- Right Middle Lung
- Right Lower Lung Which lobes of the lung will be heard laterally - left? - ANSWER- - Left Upper Lung
- Left Lower Lung Possible causes of chest pain? - ANSWER- - Anxiety/panic disorders
- Costochondritis Cardiovascular:
- Heart attack
- Pericarditis or myocarditis Respiratory:
- Bronchitis
- Pneumonia Abdominal:
- GERD Chest S/S that indicate a cardiovascular problem - ANSWER- - Exertional chest pain
- Orthopnea (SOB when supine) / paroxysmal nocturnal dyspnea (relieved by sitting up)
- Palpitations
- Edema
How to assess for dyspnea? - ANSWER- Ask the patient "Have you had difficulty breathing?" How to assess for degree of severity of dyspnea? - ANSWER- Determine its effect on patient's ADLs Possible causes of shortness of breath? - ANSWER- - Anxiety
- Activity Possible causes of cough? - ANSWER- - Irritating stimuli (ex. mucus, allergens, dust, foreign bodies)
- Inflammation
- Compression of bronchioles from tumor, enlarged lymph nodes, or pulmonary edema
- Left-sided heart failure Specific possible causes of chronic cough - ANSWER- - GERD
- Postnasal drip
- Bronchiectasis Bronchiectasis (define) - ANSWER- Reversible dilatation of the bronchi where the elastic and muscular tissue is destroyed by inflammation and infection. This damage impairs the natural drainage of bronchial secretions which can become chronically infected Possible causes of hemoptysis - ANSWER- - Bronchitis
- Cystic fibrosis
- Bronchiectasis
- Malignancy How to differentiate if coughed up blood is coming from the stomach or the respiratory tract? - ANSWER- Blood from the stomach is usually darker than blood from the respiratory tract Most common cause of acute cough - ANSWER- Viral upper respiratory infection ~Acute = < 3 weeks~ Acute coronary syndromes (S/S) - ANSWER- - Chest pain
- Dyspnea / orthopnea Pneumonia (S/S) - ANSWER- - Fever
- Productive cough How to differentiate between bacterial and viral infections in pneumonia? - ANSWER- **Bacterial pneumonia = purulent sputum (yellow or green)
- Percuss
- Auscultate Where are you most likely to hear abnormal wheezes or crackles? - ANSWER- The dependent side ^ventilation is greater in dependent lung Signs of respiratory distress - ANSWER- - Tachypnea (>25 breaths/min)
- Cyanosis or pallor
- Clubbing of fingers
- Audible signs of breathing
- Contraction of accessory muscles Stridor (define) - ANSWER- Audible high-pitched inspiratory whistling; sign of upper airway obstruction Stridor (causes) - ANSWER- - Epiglottitis
- Foreign body
- Anaphylaxis
- Tracheal stenosis from intubation
- Airway edema after device removal AP (anteroposterior) diameter - ANSWER- A measure of the shape and symmetry of the chest; Normally, the ratio of AP diameter to lateral chest diameter = 0.7-0. ~A barrel-shaped chest (anteroposterior diameter = transverse diameter) characterized aging and chronic lung disease Asymmetric expansion/unilateral delay in chest expansion occurs in what conditions? - ANSWER- - Pleural effusions
- Pleural disease (from asbestosis or silicosis)
- Lobar pneumonia
- Unilateral bronchial obstruction Crepitus (define) - ANSWER- Crackling or grinding sound over bones, joints, or skin (with or without pain) due to air in subcutaneous tissue
- Possible causes: ~Arthritis joints ~Overt fractures Fremitus (define) - ANSWER- The palpable vibrations that are transmitted through the lungs to the chest wall as the patient speaks
How to detect fremitus? - ANSWER- Use either the ball or ulnar surface of the hands to palpate and compare symmetric areas of the lungs while asking the patient to say "ninety-nine" or "one-one-one" Asymmetric decreased fremitus is indicative of what? - ANSWER- - unilateral pleural effusion
- pneumothorax
- hyperinflated lung in COPD
- neoplasm ^decreases transmission of sounds Asymmetric increased fremitus is indicative of what? - ANSWER- - unilateral pneumonia ^increases transmission through consolidated tissue Why might breath sounds be decreased to absent? - ANSWER- - Hyperinflated lung in COPD
- pleural effusion How to percuss a chest wall - ANSWER- - Hyperextend middle finger of left hand (aka pleximeter finger) and press its distal interphalangeal joint firmly on the lung surface to be percussed (do not touch any other fingers to chest)
- Position right forearm close to surface with the hand cocked upward
- Strike pleximeter finger with the tip of the right middle finger (aka plexor finger) at close to a 90 degree angle
- Withdraw striking finger quickly What to do if a louder note is needed while percussing chest wall? - ANSWER- Apply more pressure with pleximeter (left middle) finger Where to percuss on chest wall - ANSWER- From top to bottom of central posterior chest wall (1-5) and on lateral sides of posterior chest wall (6 & 7) ^pg. 322 What causes dullness when percussing chest wall? - ANSWER- Due to fluid or solid tissue Healthy lung- what sound when percussed? - ANSWER- Resonant Liver- what sound when percussed? - ANSWER- Dull Thigh- what sound when percussed? - ANSWER- Flat Gastric area- what sound when percussed? - ANSWER- Tympanic
- Heart failure Fine crackles (define) - ANSWER- - Soft, high-pitched, very brief
- Change according to body position ~mid to late inspiration~ Wheezes (define) - ANSWER- high-pitched with hissing or shrill quality Rhonchi (define) - ANSWER- low-pitched with snoring quality Wheezes (causes) - ANSWER- Due to narrowed airways
- Asthma
- COPD Pleural rub (define) - ANSWER- Coarse, grating biphasic sounds; heard primarily during expiration Pleural rub (causes) - ANSWER- - Pleurisy
- Pneumonia
- Pulmonary embolism "Silent chest" (define) - ANSWER- The absence of breath sounds & adventitious breath sounds due to advanced airway obstruction & low respiratory airflow; CLINICAL EMERGENCY!! ~can be seen in severe asthma Egophony (define) - ANSWER- Ask the patient to say "ee" If "ee" sounds like"A" = positive for egophony Bronchophony (define) - ANSWER- Ask the patient to say "ninety-nine"; should be muffled and indistinct Louder voice sounds = positive bronchophony Localized bronchophony and egophony are seen in what? - ANSWER- Lobar consolidation from pneumonia Whispered pectoriloquy (define) - ANSWER- Ask the patient to whisper "ninety-nine" or "one-two-three"; normally heard faintly and indistinctly if at all
Louder, clearer whispered sounds = positive for whispered pectoriloquy Tender pectoral muscles or costal cartilage suggests what? - ANSWER- That chest pain has a localized musculoskeletal origin How many ribs? - ANSWER- 12 pairs (11th and 12th are "floating ribs" because they have no anterior attachments) How to count ribs? - ANSWER- - Place finger in hollow curve of suprasternal notch then move down 5 cm to the sternal angle (horizontal, bony ridge where manubrium joins the body of sternum) ^Directly adjacent to sternal angle is 2nd rib What indicates rib fracture? - ANSWER- Local pain and tenderness of 1 or more ribs AP compression - ANSWER- With on hand on the sternum and the other on the thoracic spine, squeeze the chest --> increase in local pain = rib fracture! Aspiration pneumonia is more common in which lobe of the lung? - ANSWER- The right middle and lower lobes ^because right bronchus is more vertical Forced expiratory time- what is indicative of COPD - ANSWER- Patients > 60 years old with a forced expiratory time of >9 seconds are 4X more likely to have COPD Cheyne-Stokes breathing (define) - ANSWER- Periods of deep breathing alternating with periods of apnea (no breathing); normal in children & older adults during sleep When would trachea be shifted toward the involved side? - ANSWER- Atelectasis ^caused by obstruction of airflow from mucus or foreign object When would trachea be shifted toward the unaffected side? - ANSWER- Pleural effusion ^Fluid accumulates in the pleural space Pneumothorax ^air leaks into pleural space When would dullness be percussed over the lungs? - ANSWER- - lobar pneumonia
- pleural effusion
- atelectasis (dull over airless area) When would bronchial breath sounds be auscultated? - ANSWER- In lobar pneumonia When would hyperresonance be percussed over lungs? - ANSWER- - Pneumothorax (over pleural air)
Aortic & pulmonic valves close ; mitral & tricuspid valves open S1 sound corresponds to what happening? - ANSWER- Closure of the mitral valve ^Occurs @ beginning of systole when ventricular pressure exceeds atrial pressure What corresponds to systolic blood pressure? - ANSWER- Maximal left ventricular pressure S2 sound corresponds to what happening? - ANSWER- Closure of the aortic valve ^Occurs @ end of systole when ventricular pressure drops below aortic pressure S3 sound corresponds to what happening? - ANSWER- An abrupt deceleration of inflow across the mitral valve (valve btwn left atrium and ventricle) and against the ventricular wall S4 sound corresponds to what? - ANSWER- Atrial contraction **Increased left ventricular end diastolic stiffness --> decreases compliance When do right sided cardiac events occur in relation to left side? - ANSWER- Right- sided cardiac events occur slightly later than those on the left What causes the splitting of heart sounds? - ANSWER- S2 is split during inspiration: first A2 (closure of aortic valve), second P2 (closure of pulmonic valve) ^because right heart filling time is increased --> increasing right ventricular stroke volume & duration of right ventricular ejection --> delaying closure of pulmonic valve A2 vs P2 - ANSWER- A2 (closure of aortic valve) is louder than P2 (closure of pulmonic valve) Where can closure of the aortic valve best be heard? - ANSWER- Right 2nd interspace to the apex Where can closure of the pulmonic valve best be heard? - ANSWER- Left 2nd and 3rd interspaces close to the sternum When S1 is split (uncommon), where can you hear the closure of the tricuspid valve? - ANSWER- Lower left sternal border Where can you best hear closure of mitral valve? - ANSWER- Cardiac apex What acts as the cardiac pacemaker? - ANSWER- Sinus node ~where electrical impulses originate ~automatically discharges an impulse 60-90 times a min
What represents atrial depolarization on an ECG? - ANSWER- P wave What represents ventricular depolarization on an ECG? - ANSWER- QRS complex What represents ventricular repolarization on an ECT? - ANSWER- T wave Cardiac output (formula / define) - ANSWER- CO = heart rate X stroke volume It is the volume of blood ejected from each ventricle during 1 minute Stroke volume (define) - ANSWER- The volume of blood ejected with each heartbeat Preload (define) - ANSWER- The load that stretches the cardiac muscle before contraction What increases preload? - ANSWER- Inspiration Myocardial contractility (define) - ANSWER- The ability of the cardiac muscle, when given a load, to shorten Afterload (define) - ANSWER- The degree of vascular resistance to ventricular contraction; sources of resistance:
- the tone in the walls of the aorta, large arteries, and peripheral vascular tree
- volume of blood in the arterial system Pulse pressure (define) - ANSWER- The difference btwn systolic and diastolic pressures Jugular venous pressure (JVP) reflects what? - ANSWER- - Right atrial pressure
- Right ventricular end-diastolic pressure
- Central venous pressure In angina, where can chest pain radiate? - ANSWER- - Lower jaw
- Neck
- Shoulders
- Arms
- Upper abdomen What other atypical S/S may be associated with angina? - ANSWER- - shortness of breath
- paroxysmal nocturnal dyspnea
- N/V
- fatigue Aortic dissection (S/S) - ANSWER- Anterior chest pain = tearing or ripping
Diabetes = >126 mg/dL 2 - hour plasma glucose: Prediabetes = 140-199 mg/dL Diabetes = >200 mg/dL Random glucose: Diabetes = >200 mg/dL When should high-intensity statin therapy be initiated? - ANSWER- - Pts with CVD
- LDL cholesterol levels > 190 mg/dL stroke risk factors (modifiable) - ANSWER- Cigarette smoking
- Hypertension
- Hyperlipidemia
- DM Recommendations on lifestyle management address what? - ANSWER- - Cigarette smoking
- Diet (less solid fats & added sugars)
- Physical activity
- Body weight Optimal weight? - ANSWER- BMI = 18.5-24. How much physical activity? - ANSWER- Aerobic exercise 3-4 X a week ^avg. 40 minutes per session // 150 minutes of moderate-intensity per week Diet recommendations (sodium, alcohol, fats) - ANSWER- - Intake of <6 g of sodium chloride or 2.3 g of sodium per day
- Alcohol consumption of 2 or less drinks for men and 1 or less drinks for women per day
- Low in saturated and trans fats
- High in mono- & polyunsaturated fats, & omega-3 fatty acids ^nuts, avocados, fish Proper technique for obtaining BP - ANSWER- Position arm at heart level (4th intercostal space)
- Inflate cuff 30 mm Hg above pressure at which brachial or radial pulse disappears
- Listen for Korotkoff sounds of at least 2 consecutive heartbeats --> marks systolic pressure JVP =? - ANSWER- JVP = right atrium pressure = central venous pressure Also highest oscillation point, or meniscus, of jugular venous pulsations Jugular pulsations - ANSWER- 1) Atrial contraction = a wave (before S1 & systole)
- Atrial relaxation = x descent
- v wave <-- right atrial pressure rises with inflow from vena cava during right ventricular systole
- y descent <-- blood passively empties into right ventricle during early-middiastole Absent a wave indicates? - ANSWER- Atrial fibrillation Prominent a wave indicates? - ANSWER- - tricuspid stenosis
- pulmonic stenosis
- pulmonary hypertension
- SV tachycardia Prominent v wave indicates? - ANSWER- - tricuspid regurgitation
- atrial septal defects What is the most visible wave during the cycle of atrial contraction? - ANSWER- X descent JVP is assessed from pulsations in which vein? - ANSWER- Right internal jugular vein ~right external jugular vein can also be used~ JVP assessment is not useful in which age group? - ANSWER- Children under 12 years old ^too difficult to see Dominant movement of JVP? - ANSWER- Inward ^coinciding with x descent Dominant movement of carotid pulse? - ANSWER- Outward What JVP is abnormal? - ANSWER- JVP >3 cm above sternal angle, or >8 cm above right atrium = high An elevated JVP is correlated with what? - ANSWER- **Acute and chronic heart failure
The timing of the carotid upstroke in relation to S1 and S2 - ANSWER- Carotid upstroke follows S1 and precedes S Pulsus alternans (define) - ANSWER- Rhythm of pulse remains regular, but force of pulse varies beat to beat due to alternating strong and weak ventricular contractions Pulsus alternans (indicates) - ANSWER- Severe left ventricular dysfunction Where is pulsus alternans best felt? - ANSWER- Radial or femoral arteries What findings indicate pulsus alternans? - ANSWER- - Alternately loud and soft Korotkoff sounds
- Doubling of HR as cuff pressure declines Paradoxical pulse (define) - ANSWER- A change in BP during respirations: ~Systolic BP drops with inspiration~ How to assess for paradoxical pulse? - ANSWER- 1) The pressure when Korotkoff sounds are first heard = highest systolic pressure
- The pressure when sounds are heard throughout the cycle = lowest systolic pressure
- If difference between theses levels is > 10 mmg Hg, paradoxical pulse is indicated Paradoxical pulse is seen in what diseases? - ANSWER- - Asthma
- Obstructive pulmonary disease
- Pericardial tamponade
- PE Thrills (define) - ANSWER- Vibrations that are felt when palpating carotid artery Thrills indicate? - ANSWER- Aortic stenosis Bruit (define) - ANSWER- A murmur-like sound that is auscultated over carotid arteries Bruits indicate? - ANSWER- Turbulent arterial blood flow
- Atherosclerotic luminal stenosis
- Aortic stenosis
- Hypervascularity of hyperthyroidism How to assess for a bruit? - ANSWER- 1) Ask patient to stop breathing for 15 seconds
- Auscultate carotid artery with diaphragm of stethoscope
- Place diaphragm near upper end of thyroid cartilage below angle of jaw
In patients with carotid obstruction, kinking, or thrills, what should be assessed? - ANSWER- Pulse in brachial artery For cardiac examination, stand on which side of bed? - ANSWER- RIGHT side Left lateral decubitus position enables examiner to best assess what? - ANSWER- **PMI / apical impulse S3, S4, opening snap, & MITRAL STENOSIS ^listen at apex with bell of stethoscope ~brings ventricular apex closer to chest wall~ Have patient sit up, lean forward, and exhale to best assess what? - ANSWER- *Aortic regurgitation ^listen down left sternal border and at apex with diaphragm Where to hear right-sided murmurs? - ANSWER- Lower right sternal border ^accentuated with inspiration Systole and diastole in relation to S1 and S2? - ANSWER- S1-S2 = systole S2-S1 = diastole At which point in the cardiac cycle does the carotid upstroke always occur? - ANSWER- In systole immediately after S1 S1 is diminshed in? - ANSWER- First-degree heart block S2 is diminished in? - ANSWER- Aortic stenosis Aortic area on chest - ANSWER- Right 2nd interspace A palpable S2 over the aortic area indicates what? - ANSWER- Systemic hypertension A palpable S2 over the pulmonic area indicates what? - ANSWER- Pulmonary hypertension Pulmonic area on chest - ANSWER- Left 2nd interspace Right ventricular area on chest - ANSWER- Lower left sternal border (in the 3rd, 4th, and 5th interspaces) & in subxiphoid area (in pts with increased AP diameter)
In left lateral decubitus position, a diffuse PMI with diameter > 3 signals left ventricular enlargement PMI amplitude - ANSWER- Small, brisk, & tapping Hyperkinetic PMI indicates? - ANSWER- - Hyperthyroidism
- Severe anemia
- Hypertension
- Aortic stenosis
- Aortic regurgitation PMI duration - ANSWER- Normally apical impulse can be felt through first 2/3 of systole, or less, but does not continue to the second heart sound Sustained high-amplitude impulse increases likelihood of what? - ANSWER- Left ventricular hypertrophy from hypertension Diffuse, sustained low-amplitude impulse is seen in what? - ANSWER- - Heart failure
- Dilated cardiomyopathy Diastolic ventricular movements? - ANSWER- S3 & S A palpable S3 feels like what? - ANSWER- A brief, early-middiastolic impulse A palpable S4 feels like what? - ANSWER- An outward movement just before S Where to percuss when estimating cardiac size? - ANSWER- Left side of chest --> 3rd, 4th, 5th, & 6th interspaces The diaphragm is best for what? - ANSWER- - High-pitched sounds of S1 & S
- Murmurs of aortic and mitral regurgitation
- Pericardial friction rubs
- Ejection sound or OS The bell is best for what? - ANSWER- - Low-pitched sounds of S3 & S
- Murmur of mitral stenosis How to use bell when auscultated cardiac sounds? - ANSWER- Apply bell lightly
- Start at apex --> medially along lower sternal border Method of auscultating the heart? - ANSWER- **With patient lying supine with HOB at 30 degrees
- Start at apex --> left sternal border --> 2nd left interspace --> 2nd right interspace ^or other way around!
Extra sounds in diastole - ANSWER- S3, S4, or an opening snap S3 or S4 in athletes indicates what? - ANSWER- NOTHING! It is a normal finding :D What type of murmurs can be physiologic flow murmurs arising from normal heart valves? - ANSWER- Systolic murmurs Mitral stenosis is heard when in cardiac cycle? - ANSWER- Presystolic (before S1) Aortic regurgitation is heard when in cardiac cycle? - ANSWER- Early diastolic (after S2) Murmur of aortic stenosis radiates where? - ANSWER- To the neck Murmur in mitral regurgitation radiates where? - ANSWER- To the axilla Murmur of aortic regurgitation radiates where? - ANSWER- To the apex Which type of murmurs increase with inspiration? - ANSWER- Right-sided murmurs Which type of murmurs increase with expiration? - ANSWER- Left-sided murmurs Grading of murmurs - ANSWER- Grade 1: very faint; may not be heard in all positions Grade 2: quite; but heard immediately after placing stethoscope on chest Grade 3: moderately loud Grade 4: loud, with palpable thrill Grade 5: very load, with thrill; may be heard with stethoscope partly off chest Grade 6: very loud, with thrill; may be heard with stethoscope completely off chest Which murmur increases during valsalva: strain phase? - ANSWER- Hypertrophic cardiomyopathy Which murmur increases during valsalva: release phase? - ANSWER- Aortic stenosis Supranumerary glands (define) - ANSWER- Extra nipples located along the "milk line"; usually nipple and areola are small If area contains glandular tissue, increased pigmentation, swelling, tenderness, & lactation may occur during puberty, menstruation, or pregnancy Galactorrhea (define) - ANSWER- Discharge of milk-containing fluid unrelated to pregnancy or lactation; is more likely to be pathologic when:
- Bloody* or serous
- Unilateral
