Maryville NURS 612 Exam 2 with 96 Questions 100% Correct Answers 2023, Exams of Nursing

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Maryville NURS 612 Exam 2 with 96 Questions

100% Correct Answers 2023

inspect the chest - Correct answer without clothes on; 1st assess shape and size; 2nd check for symmetry; 3rd thoracic landmarks; 4th color of skin; 5th check for supernumerary nipples; 6th superficial venous patterns; and 7th observe for rib prominence thoracic landmarks - Correct answer midline trachea, costal angle, angle of ribs, intercostal spaces, suprasternal notch symmetry of chest - Correct answer thoracic expansion at costal angle, w/o use of accessory muscles hx questions for cc of resp issue - Correct 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 - Correct answer 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 - Correct answer term for abnormally shallow respirations tachypnea - Correct answer term for resp rate greater than 20, but consistent and may occur during hyperventilation; often a symptom of pain bradypnea - Correct 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 - Correct answer term for fast and deep, heavy respirations, can be caused by exercise, anxiety, and CNS and metabolic diseases hyperpnea - Correct answer term for abnormally deep respirations kussmaul respirations - Correct answer deep and mostly rapid respirations, used to describe resp effort of metabolic acidosis cheyne stokes respirations - Correct 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 with brain damage

biot respirations - Correct answer irregular breathing that varies in depth and is interrupted irregularly by intervals of apnea; associated with severe and persistent increased intracranial pressure, resp compromise from drug poisoning, or brain damage at the medulla and generally equals poor prognosis peripheral areas related to respiratory assessment - Correct answer observe the lips and nails for cyanosis or pallor; lips for pursing; fingers for clubbing; and alae nasi for flaring pleural friction rub - Correct answer dry, rubbing, or grating sound; palpable, coarse, grating vibration; usually on inspiration; caused by inflammation of the pleural surfaces; think feel of leather rubbing on leather thoracic expansion - Correct 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 - Correct answer crackly/crinkly sensation that can be palpated and heard, a gentle bubbly feeling; indicates air in the subcutaneous tissue from a rupture somewhere in the resp system, or infection with gas producing organism palpating the chest and trachea - Correct answer palpate the throracic muscles and skeleton; feeling for pulsations, areas of tenderness, bulges, depressions, masses, and unusual movement tactile fremitus - Correct answer palpable vibration of the chest wall that results from speech or other verbalizations. best felt posteriorly and laterally at the level of the bifurcation of the bronchi; have patient say "99" while you palpate with palmer surface of fingers or ulner aspect of the hand; use firm, light touch abnormal tactile fremitus - Correct answer decreased of absent fremitus may be caused by excess air in lungs or may indicate emphysema, pleural thickening, or effusion, massive pulm edema, or bronchial obstruction. Increased fremitus often coarser or rougher in feel, caused by presence of fluids or solid mass within the lungs. 7 characteristics of enlarged lymph nodes - Correct answer location, size and shape, consistency, mobility, discreteness, tenderness, and warmth occipital lymph nodes - Correct answer lymph nodes at the base of the skull postauricular lymph nodes - Correct answer lymph nodes over the mastoid process, behind the ear preauricular lymph nodes - Correct answer lymph nodes in front of the ear

parotid and retropharyngeal lymph nodes - Correct answer lymph nodes at the angle of the mandible (tonsillar) submandibular lymph nodes - Correct answer lymph nodes halfway between the angle and tip of the mandible submental lymph nodes - Correct answer lymph nodes in the midline behind the tip of the mandible superficial cervical lymph nodes - Correct answer lymph nodes at the sternocleidomastoid muscle posterior cervical lymph nodes - Correct answer lymph nodes along the anterior border of the trapezius muscle cervical lymph nodes - Correct answer lymph nodes deep to the the sternocleidomastoid, must probe gently w/ your thumb and fingers around the muscle supraclavicular area lymph nodes - Correct answer lymph nodes that you must probe deeply in the angle formed by the clavicle and sternocleidomastoid muscle, common sites for metastatic disease axillary lymph nodes - Correct answer lymph nodes found by supporting pt's forearm w/ your non exam arm; and by bringing the palm of your exam hand into the axilla. Let the soft tissues roll b/w your fingers and the pt's chest wall and muscles. Rotate your fingertips and palm to feel for the nodes. epitrochlear lymph nodes - Correct answer lymph nodes found by supporting pt's arm in one hand as you explore with your other hand in the groove of the elbow b/w the triceps and biceps muscles inguinal lymph nodes - Correct answer lymph nodes found by having the patient lie supine, feel for the superior inguinal lymph nodes (femoral) that lie close to the surface over the inguinal canals. Assess the inferior superficial inguinal lymph nodes which lie deeper in the groin 6 characteristics of skin assessment - Correct answer color, uniformity, thickness, symmetry, hygiene, and lesions popliteal lymph nodes - Correct answer lymph nodes found by flexing the supine pt's knee and wrapping your hand around it and palpate the fossa with your fingers 5 characteristics of the skin - Correct answer moisture, temperature, texture, turgor, and mobility

documentation of skin lesion - Correct answer size, shape, color, texture, elevation, depression, attachment, exudate, configuration, location and distribution, subtle details, transillumination, and shine a wood's lamp on it nevi - Correct answer normal skin lesions macule - Correct answer a flat, circumscribed area that is change in color of skin, less than 1 cm (freckles, flat moles, measles) papule - Correct answer an elevated, firm, circumscribed area, less than 1 cm (wart, elevated moles, lichen planus) patch - Correct answer a flat, nonpalpable, irregularly shaped macule greater than 1 cm (vitiligo, port wine stains, mongolian spots, cafe au lait) plaque - Correct answer an elevated, firm and rough lesion with flat top surface greater than 1 cm (psoriasis, seborrheic, and actinin keratosis) wheal - Correct answer elevated, irregular shaped area of cutaneous edema; solid, transient variable diameter (insect bites, urticaria, allergic rxn) nodule - Correct answer elevated, firm, circumscribed lesion; deeper in dermis than a papule, 1 to 2 cm in diameter (erythema nodosum, lipoma) tumor - Correct answer elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter (neoplasms, benign tumor, lipoma) vesicle - Correct answer elevated, circumscribed, superficial not into the dermis; filled with serous fluid; less than 1 cm in diameter (varicella, herpes zoster) bulla - Correct answer vesicle greater than 1 cm in diameter (blister, pemphigus vulgaris) pustule - Correct answer elevated, superficial lesion; similar to a vesicle but filled with purulent fluid (impetigo, acne) cyst - Correct answer elevated, circumscribed encapsulated lesion; in dermis or subcutaneous layer, filler with liquid or semisolid material (sebaceous cyst or cystic acne) telangiectasia - Correct answer fine, irregular, red lines; produced by capillary dilation (rosacea)

scale - Correct answer heaped up, keratinized cells; flaky skin; irregular; thick and thin; dry or oily; variation in size (flaking of the skin with seborrheic dermatitis, following drug rxn, dry skin) lichenification - Correct answer rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surface of extremity (chronic dermatitis) keloid - Correct answer irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing (keloid formation post surgery) scar - Correct answer thin to thick fibrous tissue what replaces normal skin following injury or laceration to the dermis (healed wound or surgical incision) excoriation - Correct answer loss of the epidermis; linear hollowed out, crusted area (scabies, abrasion or scratch) fissure - Correct answer linear crack or break from the epidermis to the dermis; may be moist or dry (athlete's foot, cracks at the corner of the mouth) erosion - Correct answer loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla (varicella, variola after rupture) ulcer - Correct answer loss of epidermis and dermis; concave; varies in size (decubiti, stasis ulcers) crust - Correct answer dried serum, blood, or purulent exudates; slightly elevated; size varies; brown, red, black, tan, or straw-colored (scab on abrasion, eczema) atrophy - Correct answer thinning of skin surface and loss of skin markings; skin is translucent and paper like (striae, aged skin) annular - Correct answer round, active margins with central clearing (tinea corporis, sarcoidosis) examining the hair - Correct answer palpate its texture, scalp hair may be coarse or fine, and curly or straight. Should be shiny, smooth, and resilient 3 characteristics of hair - Correct answer color, distribution, and quantity 6 characteristics of nails - Correct answer color, length and condition, edges, configuration, symmetrical, and clean/smooth/neat 4 characteristics nail palpation - Correct answer texture, firmness, thickness, and adherence

basal cell carcinoma - Correct answer cancer that arises in the basal layer of the epidermis; shiny nodule that is pearly or translucent; may be pink, red, black, white, tan or brown; occurs on exposed parts (face, ears, neck, scalp); persistent sore or lesion that has not healed; may have crusting, bleed, or itchy; most common type squamous cell carcinoma - Correct answer malignant tumor arises in the epithelium; occurs in sun exposed areas; persistent sore that has not healed; may have crusting or bleeding; elevated, wart-like growth with central depression; 2nd most common malignant melanoma - Correct answer lethal skin cancer; melanocytes migrate into the skin, eye, CNS, and mucous; less than half develop from nevi; exact cause unknown; new mole or preexisting mole that has changed or is changing; ABCDE changes in moles ABCDE changes in moles - Correct answer asymmetry, borders, color, diameter, and evolution kaposi sarcoma - Correct answer arises from endothelium and epitheal layer of skin; caused by kaposi sarcoma herpes virus 8, common in immunocompromised patients (HIV/AIDS) vesicular breath sounds - Correct answer low pitch, low intensity; heard over healthy lung tissue bronchovesicular breath sounds - Correct answer heard over major bronchi; medium pitch and moderate intensity bronchial breath sounds - Correct answer high pitch and high intensity; heard over trachea hamman sign - Correct answer lung sound: mediastinal crunch; greater variety of sounds loud crackles, clicking, and gurgling sounds over pericardium; they are synchronous with the heart beat and not particularly with respirations; more pronounced toward end of expiration and easiest to hear when pt leans on the left of lies on the left side; found with mediastinal emphysema crackles - Correct answer lung sound: discontinuous, mostly during inspiration; may be fine, high pitched, and relatively short in duration or low pitched and relatively longer in duration rhonchi - Correct answer lung sound: sonorous (low pitched) wheezes are deeper, more rumbling, more pronounced during expiration; more likely to be prolonged and continuous and less discrete than crackles

wheezes - Correct answer lung sound: sibilant (high pitched) wheezes; continuous high pitched musical sound (almost a whistle) heard during inspiration or expiration vocal resonance - Correct answer ask pt to say numbers "99" or words, transmitted sounds are usually muffled and indistinct and are best heard medially bronchophony - Correct answer greater clarity and increased loudness of spoken sounds egophony - Correct answer when intensity of the spoken voice is increased and there is a nasal quality whispered pectoriloquy - Correct answer extreme bronchophony; occurs with presence of consolidation; a whisper can be heard clearly and intelligently with a stethoscope 6 characteristics of inspecting head and face - Correct answer head position, facial features and shape/symmetry, tics, shape and unusual features, skull, and scalp tics - Correct answer spasmodic muscular contractions of the face, head, and neck; may be associated with pressure or degenerative changes to facial nerves or tourette syndrome 5 areas to palpate for head and neck - Correct answer skull, hair, temporal arteries, temporomandibular joint, and salivary glands hypercalcemia - Correct answer on percussion of the masseter muscle, facial spasms are associated with ..... vascular anomaly - Correct answer on auscultation of the temporal region, over the eyes and below the occiput, a bruit suggests a .... cerebral aneurysm - Correct answer pt's with diplopia, a bruit or blowing sounds over the orbit are rarely heard, and may suggest an expanding ..... 6 characteristics of neck inspection - Correct answer symmetry; trachea alignment; anterior & posterior triangles; fullness at the base ; look for abnormalities ; and jugular vein distention & carotid artery prominence CN XI - Correct answer cranial nerve that you test when you evaluate the muscle strength of the neck 5 areas of neck palpation - Correct answer trachea; hyoid bone, thyroid & cricoid cartilages; tracheal tug; paravertebral muscles & posterior spinous processes; and lymph nodes of the head & neck

inspection of thyroid - Correct answer with the pt's neck extended, provide a cup of water and observe from the side as pt swallows. characteristics of thyroid on inspection - Correct answer note size, symmetry, contour, and movement with swallowing characteristics of thyroid on palpation - Correct answer note size, shape, configuration, consistency, tenderness, or nodules auscultate for bruits - Correct answer What do you do it the thyroid is enlarged? shotty lymph nodes - Correct answer small, moveable, discrete, nodes that feel like BBs or buckshot under the skin; generally clinically insignificant and usually represent enlargement of lymph nodes following a viral infection