Prep U Respiratory & Cardiac – Flashcards

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect what?

The term "base of the heart" refers to what area of the heart?

in order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

What action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

A nurse cares for a client who suffered from a myocardial infarction 2 days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring with the pericardium?

What muscle is primarily responsible for thoracic cavity enlargement?

While auscultating the heart at the 3rd intercostal space, left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse would document what?

When auscultating the lungs, the nurse listens over symmetrical lung fields for what?

A 62 y.o. construction worker presents to the clinic reporting almost a chronic cough and occasional SOB that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has no weight gain or loss, fever, or night sweats. His past medical history is significant for high BP and arthritis. He has smoked 2 ppd for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with 2 children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His BP is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His HEENT examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

A client in the ER tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. The client has a condition known as what?

A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying it as what?

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any SOB, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is the most appropriate to further assess the cause for the cough?

Where are the heart and great vessels located in the human body?

True/False: The nurse auscultates the apical pulse then palpates the PMI. To best palpate the PMI, the nurse places 2 fingers at the left border of the heart in the 5th intercostal space

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax?

Across the lifespan, a nurse knows that the female heart ______

A 17 y.o. high school senior presents to the clinic in acute respiratory distress. B/w shallow breaths he states he was at home finishing his homework when he suddenly began to have right-sided chest pain and severe SOB. He denies any recent traumas or illnesses. His past medical history is unremarkable. He is an honor student and on the basketball team. His parents are both in good health. He denies any recent weight gain or loss, fever or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths/minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms?

Which of the following would be most important for the nurse to remember when auscultating the thorax? a)Be alert to the client's comfort and offer rest periods b)Have the client breathe deeply through the mouth c)Listen at each site for at least one complete respiratory cycle d)Auscultate the base at the level of the sixth rib

A 36-year-old teacher presents to the clinic with sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps. Acetaminophen and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced with one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. Examination finds the client to be distressed, leaning over, and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall. What disorder of the chest best describes this presentation? a) Angina pectoris b) Pericarditis c) Dissecting aortic aneurysm d) Pleural pain

A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort? a) The client will respond negatively to increased stimuli. b) There is loss of involuntary respiratory control. c) There is an increased level of carbon dioxide in the blood. d) The client's oxygen levels in the blood will be increased.

It has become apparent that there is not a lifetime immunity to pertussis for those who received the childhood DPT vaccine. a) True b) False

A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe? a)Pneumonia b)Chronic obstructive pulmonary disease (COPD) c)Spontaneous pneumothorax d)Asthma

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what? a) Rales b) Wheezes c) Stridor d) Crackles

When percussing the posterior lung fields, which of the following findings is expected? a) Tympany over 11th interspace, right scapular line b) Dullness over the lung bases c) Hyperresonance over apices d) Resonance over all lung fields

A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort? a) There is loss of involuntary respiratory control b) The client's oxygen levels in the blood will be increased c) There is an increased level of carbon dioxide in the blood d) The client will respond negatively to increased stimuli

While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following? a) Pneumonia b) Funnel chest c) Pectus excavatum d) Emphysema

A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next? a) Perform a complete respiratory assessment. b) Ask about any medications being used for hypertension. c) Ask how long ago he was diagnosed. d) Refer him for further evaluation.

A group of students is reviewing the vertical reference lines of the thorax. They demonstrate understanding when they identify which line as a reference line for the posterior thorax? a) Vertebral line b) Sternal line c) Right midclavicular line d) Midaxillary line

When assessing the apices of the lungs, the nurse would locate them at which position?

How should a nurse position a client to accurately auscultate the right middle lobe of the lung?

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is

What would the nurse expect to hear when auscultating the lungs of a client with pleuritis?