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Nursing test 3


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This is located approximately 2 inches below the sternal notch
Angle of Louis
located at the 2nd ICS right of the sternum
Aortic Area
located at the 2nd ICS left of the sternum
Pulmonic area
Located at the 4th ICS left of the sternum
Tricuspid Area
Located at the 5th ICS mid-clavicular line, should also be the Point of Maximal Impulse
Mitral (Apex) area
This is located at the 3rd ICS on the left of the sternum
Erb's point
What is located at the tip of the sternum
epigastric area
What is a good way to remember the areas to auscultate of the heart?
APT M and sometimes APE TM
To determine Heart rate you would listen and count for 60 seconds to measure the apical pulse over what area?
PMI point of maximal impulse or mitral area
These beats occur in a regular fashion
These beats are not regular, but the irregularity occurs in a predictable manner
regularly irregular
These beats have no regularity or predictability to the beat?
Irregularly irregular
Mitral and tricuspid valve closure, is the "lub" portion of "lub-dub" and is the most distinct heart sound
Aortic and pulmonary valve closure, the "dub" portion. These sounds are best heard with the diaphragm of the stethoscope.
S1 is heard best where?
S2 is heard best where?
Aortic Area
If you are having difficulty determining the difference between S1 and S2 what should you do?
Palpate the carotid pulse while you are listening at the apical area. When you feel the pulse, the sound you are hearing is S1.
This period begins with the 1st heart sound, and ends with the 2nd heart sound. Ventricular contraction is occuring at this time.
This period begins with the 2nd heart sound, ends with the 1st heart sound of the next beat, this is a period of ventricular relaxation.
Less than 60 beats/minute would be considered what? and over 100 beats/minute would be considered?
If enough time elapses between the closure of the right side valve and the left side valve, you may be able to hear a two phae S1 and S2, what is this called?
Ventricular gallop, heard directly after s2 or "dub" caused by early, rapid filling of the ventricle, sounds like "lub-dub-ah" or Ken-tuck-y. This is normal in children, but pathologic in adulats and indacative of fluid overload, what
This is called atrial gallop; heard just before s1 and is caused by increased ventricular stiffness, sounds like "ta-lub-dub" or Ten-nes-see. This is always pathologic and indicates too much fluid.
These are swishing or blowing sounds caused by turbulence of blood flow across a valve to through an abnormal heart wall opening, they are characterized by timing, location, radiation, quality, pitch, shape, and duration.
This type of murmur is heard with S1 and before S2. If you palpate the carotid pulse, you will hear the murmur immediately after you feel the pulse. It sounds like lub-shh-dub? This type of murmur can be a normal abnormality in children
systolic murmur
This type of murmur is heard after S2 and before S1 beat again. They are soft and lower-pitched and sounds like lub-dub-shh?
Diastolic murmur
This is heard over a vessel other than the heart. It sounds similar to a murmur. It is common in people who have anemia, hyperthyroidism, which can elevate cardiac output.
This is a vibration that is felt over the area of the murmur?
This sound can occur from a mitral valve prolapse or mechanical heart valve. They can also be sternal and can be caused by instability of the sternum after surgery (in this case it is a sternal sound and not a heart sound.
This is a very early diastolic sound, it is caused by opening of a thickened mitral valve and sounds like clicks. Occurs when a diseased leaflets close and they may have the tendency to stick together, the separation when they open produce this sound.
Sometimes these pulses are hidden and you may have to feel across the top of the foot to feel them? What are these pulses called?
Dorsalis Pedis
These pulses are behind and below medial malleolus of the ankle (inside of the ankle). To feel pick the tissue up against the ankle bone to feel this pulse. or cup heel and push up
Posterior tibial
This is an ultrasound instrument that amplifies sounds and is used to locate pulses?
What can an absence of pulses indicate?
clot in an artery
What does JVD indicate?
fluid overload or cardiopulmonary disease.
This is a condition in which the angle between the nail and nail bed is 180 degrees or greater. may be caused by a long-term lack of oxygen or sometimes in a asthma or smoker patients
How do you treat edema?
With diuretics
This is a check of circulation to the distal extremities?
Capillary Refill
what is the time for normal capillary refill?
less than 3 seconds.
This is an obvious lifting of the chest wall during contraction, and may indicate an enlarged heart?
The locatio of the apical impulse changes as the child's rib cage grow. Where is it in children under 7 years of age?
4th intercostal space just medial to the left midclavicular line.
What part of the stethoscope do you use to detect lower pitched sounds?
With this type of arrhythmia, the childs heart rate is faster on inspiration and slower on expiration. Have the child take a deep breath and hold it while you listen to the heart rate. The rhythm should become regular during inspiration and expiration.
If the child has a potential murmur you would ausculatate the heart in what positions.
sitting, reclining, and standing
If the blood pressure in the leg is lower than in the arm this may indicate what?
coarctation of the aorta
This is created by turbulence of blood flow due either to a narrowed arterial lumen or to a condition such as anemia or hyperthyroidism which elevates cardiac output, what is this called?
This frequently accompanies a bruit, and is a vibrating sensation like the purring of a cat or water running through a hose. It indicates turbulent blood flow due to arterial obstruction, what is this?
Bilateral jugular vein distention may indicate what sided heart failure?
This is usually louder at the apical area?
This is louder at the base of the heart?
If you feel the carotid arteries and detect asymetric pulse volumes this may indicate what two things?
stenosis or thrombosis.
This is the area of the chest overlying the heart that is inspected and palpated for the presence of abnormal pulsations or lifts or heaves.
Difference between the apical and radial pulse
pulse deficit
These sound like a pleural rub, but coincide with heartbeat, how would you differentiate between pleural rubs and cardiac rubs
have the patient hold their breath and if the rub stops it is pleural if it continue it is cardiac
What order do you assess the heart?
inspection, palpation, and auscultation.
A scaphoiod or sunken abdomen is abnormal and may indicate what?
The abdomen is divided into how many quadrants?
A vertical line if drawn from the xiphoid process to the middle of the pubic synphysis and a horizaontal line is drawn across what?
These organs are located in what quadrant: Duodenum, Gallbladder, Liver, Right adrenal gland and upper kidney, hepatic flexure of the colon, head of the pancreas, and sections of the ascending and transverse colon?
right upper quadrant
What quadrant are these organs located in: Stomach, spleen, left adrenal gland and upper kidney, splenic flexture of the colon, body of the pancreas, left lobe of the liver, and sections of the transverse and desceding colon?
left uppper quadrant
These organs are located in what quadrant: Cecum, appendix, right ovary and fallopian tube (female), portion of the uterus, right spermatic cord (male), right ureter and lower kidney pole, and section of ascending colon?
right lower quadrant
These organs are located in what quadrant: sigmoid colon, left ovary and fallopian tube (female), part of the uterus, left spermatic cord, left ureter and lower kidney pole, and section of the descending colon?
left lower quadrant
What pain is perceived in an area other than its origin. this may occur relatively near the affected organ or at some distance from it?
referred pain
The original and referred sites are supplied with what nerves for pain from the same spinal cord segments?
efferent nerves
Appendis pain refers to what two places?
right lower quadrant and umbilical area
Duodenal pain refers to what three areas?
area above the umbilicus, the right posterior scapula and shoulder area.
Gallbladder pain refers to what two places?
right upper quadrant and right posterior scapular area.
This pain refers to the sternal area, neck, jaw, face, shoulder, and arms
This pain refers to the flank or lumbar area and may radiate to inguinal area and gentals with renal caliculi.
This pain refers to the left upper quadrant and epigastric area, and may refer to left shoulder and back.
May need to measure what for trending?
What order must you assess the abdomen? Why?
inspect, auscultate, palpate and percussion. Palpatation and percussion can either stimulate or stop bowel sounds which can cause false results.
What part of the stethoscope do you auscultate the abdomen with?
These are irregular gurgling noises occuring about every 5 to 20 seconds?
bowel sounds
What three terms are used to document bowel sounds?
Absent, hypoactive, and hyperactive
This is when no bowel sounds are heard in 3-5 minutes, it indicates cessation of intestinal motility. Can occur immediately post-op and may indicate that the patient has some sort of pathology of the bowels or obstruction. May also indicate peritonitis o
absent bowel sounds
These are extremely soft and infrequent, may indicte decreased bowel motility. May be caused by inflammation or developing paralytic ileus.
hypoactive bowel sounds
These are high-pitched, loud, rushing sounds and may indicate increased GI motility and may be caused by diarrhea, early bowel obstruction, or use of laxatives. Can also indicate gastroenteritis.
hyperactive bowel sounds.
What two things do you percuss on the abdomen?
liver borders and gastric bubble
What type of sounds are found over the liver, spleen, and full bladder?
What type of sounds are found over the stomach or the intestines when an obstruction is present and also found over areas beyond the edge of the liver?
What things are contraindicated when percussing or palpating the abdomen?
pulsating abdominal mass, appendicitis, transplanted organs, enlarged spleen, polycystic kidneys, or malignancies
Toddlers have a characteristic "pot belly" until what age?
If an enlarged kidney or mass is detected do not continue to palpate the kidney. Pressure on the mass may release what?
cancerous cells
The seriously ill patient may have difficulty doing what due to pain, physical limitation, fear, inability to tolerate positioning, etc.?
If a patient cannot communicate verbally due to the presence of tubes and equipment use nonverbal means of communication to yes-no questions such as?
head nods, shakes, and eye blinks
If you patient is literate you may use what?
pen and paper, letter and number boards or question boards with a pointing utensil
If you patient is illiterate and cannot communicate you may use what?
picture boards
Your seriously ill patient may have difficulty communicating because of pain, what can you do to ease their pain?
Be watchful for painful positions or for physical effects of some procedures, what can you do to help change a patients position without inflicting too much pain?
ask another nurse for assistance.
What patient would these tips for physical examination be for: be certain to attend to this patient's heightened need for security and privacy, state in advance what you are going to do and what the patient can expect, be certain to let the patient know
Anxious patient
What are some of the reasons a patient may be withdrawn?
fear, pain, poor prognosis, culture, unfamiliar surrounds, they may be dying, or that just may be the way they are
What type of patient would you use close ended questions with?
Overly talkative patients
Over talkative behavior is usually a response to what?
How do we remember to manage hostility?
c- check to see if everyone is safe
a- agree with affect, not opinion
l- listen to the patient
m- medical care is the common goal
d- don't debate with the patient
o-old behavior is a good predictor of future behavior
w- walk away if you feel threatened or abused.
n-determine the patients needs
What is one thing you must know when dealing with abuse?
Know you facilities policies and procedures with dealing with abuse.
Always position yourself between the patient and what when dealing with abuse?
What patient would this modified exam be used for? Be certain to attend to need for privacy, explain everything you are going to do, slow down, ask permission before you touch the patient, may need another caregiver in the room with you, and watch for cu
hostile patient
With this patient you would assess level of impairment, eliminate distractions, direct your questions and attention to the patient, not the family, tailor your language to the patient's level, but be careful not to "talk down" to the patient, i
Cognitively impaired person
With a cognitively impaired patient, try to establish a rapport with the patient before the exam begins, have a family member present, start with a less intrusive exam first, work up to more intrusive as trust builds, and start with less painful interven
If you believe that you patient is incompetent, what should you do first?
speak to your supervisor to find out who is responsible for care decisions and check with policies and procedures of your facility.
Why would you use a sign language interpretor for hearing impaired patients?
because family member may put a spin on what the patient actually said and the patient
What patient would this exam be used for? Take decreased flexibility into account, know the normal signs of aging and don't confuse them with pathology, review medications for possible side effects or impact upon physical findings, and move the patient s
Older patient
With obese patients what areas of poor hygiene would you assess?
under breast and between fat folds.
If you are uncomfortable about the stability of a pregnancy what should you do?
get help from an OB nurse
Why is a sidelying or sitting position best for pregnant women?
because flat in bed can make it difficult for the patient to breath and can cause decreased blood flow to the placenta.
What must you be careful about when assessing a pregnant patient?
position changes: fainting
and falls due to loss of balance due to changes in center of gravity.
What is the number one reason nurse's get sued?
over medication administration
The Institute of Medicine estimates that at least how many preventable adverse drug events occur in the U.S. each year?
1.5 million
How many medication deaths occur each year in hospitals?
For each adverse drug event that takes place in a hospital it adds an average of _______ to the cost of that hospital.
What three people can prescribe medications?
physician, advanced practice nurse, and physician's assistant.
What is the safest type of prescription?
Who double check's the order's correctness as far as appropriateness for patient's illness, dosage, and times administered?
Who is the last person to make sure that the patient receives the right medication and dose?
In type of drug distribution system each patient has a specified area (drawer, cabinet, etc) in which the medications ordered are kept. Generally has 24 hour's worth of medication stocked at a specific time each day.
Drug cart or drawer
What is downfall of a drug cart or drawer?
Some medications may still be in there that are no longer a prescribed medication for the patient and does not allow well for order changes or new orders within the 24 hour period.
Bulk amounts of medication are kept in a specific area of each nursing unit(drug room) and are available for use on a dose by dose basis. What are these
Stock medications
These medications are appropriate for medications that are routinely prescibed or prescribed on a prn basis i.e. laxatives, antacids, ASA, and tylenol.
Stock medications
What is the downfall of stock medications?
This system circumvents the pharmacist check of the medication.
With this system each nurse is issued a code for access to medications. These systems are becoming very sophisticated, some now have each patient issued a bar code and the medications being checked by bar code prior to administration.
Computer- controlled systems
What are the six rights of medication administration?
right drug, right dose, right patient, right route, right time, and right documentation.
competent people have the ability to do what?
Refuse a medication regardless of the consequences.
What is one question you should always ask your patients?
Do you have any allergies?
These things must be done during what? history, history of allergies, medication data, diet history, patient's perceptual or coordination problems, patient's current condition, patient's attitude about medication use, patient's knowledge and understandin
In assessment, be certain to include questioning regarding the patient's use of what and other what products? There may be strong adverse reactions between some widely available products and prescription drugs.
herbal remedies and OTC medications
What can cause bleeding?
Ginko Biloba
What causes Gi disturbances, allergic reactions, fatigue, dizziness, confusion, dry mouth, and photosensitivity?
St. Johns Wort
What causes hypertension, onsomnia, arrhythmia, nervousness, tremor, headache, seizure, CVA, MI, and kidney stones?
what causes sedation, oral and lingual dyskinesia, torticollis, oculogyric crisis, exacerbation of parkingson's diseas, painful twisting movements of the trunk and rash?
Herbal Drug interactions: Ginkgo: ASA coumadin, Plavix, persantine, ticlid; St. Johns wort- antidepressants; Ephedra- caffeine, decongestants, stimulants;Kava- sedatives, sleeping pills, antipsychotics, alcohol; Ginseng interacts with what?
What are the three key goals or expected outcomes of drug administration?
Drug's therapeutic effect is achieved, no complications related to the medication or the method of administration and the patient and family will demonstrate understanding of self-administration of drug if appropriate.
When should you document administration of a drug?
After the drug has been administered.
These are a crucial part of what process? Monitor physical response to medication, monitor behavioral response to medication, observe injection sites for bruises, inflammation, and infection, determine patient's understanding of drug therapy, determine p
What is one check done for accurate pediatric dosage?
Have another nurse double check your calculations
What are five factors affecting older adult medications?
polypharmacy, self-prescribing medications, OTC meds, misuse of meds and noncompliance
What is a substance administered for the diagnosis, cure, treatment, or relief of a symptome or for prevention of disease?
What term has the connotation of an illicitly obtained substance such as heroin,cocaine, or amphetamines?
What name is given before a drug becomes official?
generic name
What is the name under which it is listed in one of the official publications?
official name
What is the name by which a chemist knows it; this name describes the constituents of the drug precisely?
chemical name
What is the name given by the drug manufacturer? A drug may have several of these
trade or brand name
This is the study of the effect of drugs on living organisms?
This is the art of preparing, compounding, and dispensing drugs and can also refer to the place hwere drugs are prepared and dispensed?
This is a person licensed to prepare and dispense drugs and to make up prescriptions?
In the United States, official drugs are those so designated by the federal food,Drug, and Cosmetic act, where are this drugs listed?
United States Pharmacopeia
This is a book containing a list of products used in medicine, with descriptions of the product, chemical tests for determining identity and purity, and formulas and prescription?
This is also referred to as the desired effect, this is the primary effect intended, that is the reason the drug is prescribed?
therapeutic effect
This of a drug is one that is unintended. They are usually predictable and may be either harmless or potentially harmful. Also referred to as secondary effect
side effect
More severe side effects are called what and may justify the discontinuation of a drug?
adverse effects
This results from overdosage, ingestion of a drug intended for externa. use, and buildup of a drug in the lbood because of impaired metabolism or excretion.
drug toxicity
This is an immunologic reaction to a drug?
Drug allergy
A severe allergic reaction usually occurs immediately after the administration of the drug and is called an ______ reaction. This response can be fatal if the symptoms are not noticed immediately and treatment is not obtained promptly. The earliest sympt
This exists in a person who has unusually low physiologic response to a drug and who requires increases in the dosage to maintain a give therapeutic effect.
drug tolerance
What is the increasing response to a repeated doses of a drug that occurs when the rate of administration exceeds the rate of metabolism or excretion. As a result, the amount of the drug builds up in the client's body unless the dosage is adjusted.
cumulative effect
What effect is unexpected and individual? Underresponse and overresponse to a drug may be this as well. Also, the drug may have a completely different effect from the normal one or cause unpredictable and unexplainable symptoms in particular client?
Idiosyncratic effect
What occurs when the administration of one drug before, at the same time as, or after another drug alters the effect of one or both drugs? The effect of one or both drugs may be either increased or decreased.
drug interaction
What disease caused unintentionally by medical therapy can be due to drug therapy? such as hepatic toxicity resulting in biliary obstruction, renal damage, and malformations of the fetus as a result of specific drugs taken during pregnancy are examples.
Iatrogenic disease
What is a person's reliance on or need to take a drug or substance. The two types are physiologic or psychologic
Drug dependence
This type of dependence is due to biochemical changes in body tissues, especially the nervous system. These tissues come to require the substance for normal functioning.
Physiologic dependence
This type of dependence is emotional reliance on a drug to maintin a sense of well-being, accompanied by feeling of need or cravings for that drug. They vary ranging from mild desire to craving and compulsive use of the drug.
Drug _________ denotes a mild form of psychologic dependence. The individual develops the habit of taking the substance and feels better after taking it. The habituated individual tends to continue the habit even though it may be injurious to health.
______ drugs, also called street drugs, are those sold illegally. Illicit drugs are of two types: (a) drugs unavailable for purchase under any circumstances, and (b) drugs normally available with a prescriptioin that are being obtained through illegal ch
Illicit drugs
What is the time after administration when the body initially responds to the drug?
Onset of action
What is the highest plasma level achieved by a single dose when the elimination rate of a drug equals the absorption rate.
Peak plasm level
What is the time required for the elimination process to reduce the concentration of the drug to one-half what it was at initial administration?
Drug half-life
What is a maintained concentration of a drug in the plasma during a series of scheduled doses?
What is the process by which a drug alters cell physiology?
One of the mechanisms is the drug interaction with a cellular receptor to produce a response known as an ___________.
Drugs that have no special pharmacologic action of their own but that inhibit or prevent the action of an agonist are called specific ____________.
What is the study of the absorption, distribution, biotransformation, and excretion of drugs?
What is the process by which a drug passes into the bloodstream?
What is the transportatio of a drug from its site of absorptio to its site of action?
Biotransformation, also called detoxification or metabolism is a process by which a drug is converted to a less active form. The products of this process are called what?
This type of metabolite has a pharmacologic action itself?
active metabolite
This type of metabolite does not have a pharmacologic action?
inactive metabolite
What is the process by which metabolites and drugs are eliminated from the body?
Drug _______ is when a client's response to a drug is influenced by age, gender, size, and body composition.
Drug metabolism is gentically determined and, as a result, race may effect a drug response. This is call ________ polymorphism.
_______ can affect the action of medication. For example, vitamin K found in green leafy vegetables can counteract the effect of an anticoagulant such as warfarin.
Illness and disease can also affect the action of drugs. For example, aspirin can reduce the body temperature of a feverish client but has no effect on the body temperature of a client without what?
This route of administration is the most common, least expensive, and most convenient route for most clients. Because the skin is not broken as itis for an injection, this is the safest as well. Disadvantages are unpleasant taste of the drugs, irritation
In this type of administration a drug is placed under the tongue, where it dissolves. In a relatively short time, the drug is largely absorbed into the lbood bvessels on the underside of the tongue.
The medication should not be swallowed. Nitroglyc
This means "pertaining to the cheek". In this administration a medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves. The drug may act locally on the mucous membranes of the mouth or systemically whe
This route is defined as other than through the alimentary or repiratory tract; that is, by needle.
A ____ order indicates that the medication is to be given immediately and only once
The ______ order or one-time order is for medication ot be given once at a specified time.
The ____ order may or may not have a termination date. This order may be carried out indefinitely until an order is written to cancel it, or it may be carried out for a specified number of days.
a ______ order, or as nedded order; permits the nurse to give a medication when, in the nurse's judgement, the client requires it. The nurse must use good judgement about when the medication is needed and when it can be safely administered.
Necessary foods such as milk or orange juice should not be used to mask the tast of medications, because the ____ may develop unpleasant associations and refuse that food in the future.
The nurse is advised to stay with patients until they have _____ the medications
Oral medications are contraindicated when a client is vomitting, has gastric or intestinal suction, or is unconscious and unable to swallow. Such patients in a hospital are usually on orders for nothing by mouth or ______.

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