CCRI Nursing 1010, exam 2 Questions And Answers Graded A+

Murmurs - Answer-soft blowing, rumbling, crunching. 1. Systolic- murmur occurs between S1 and S2 2. Diastolic- murmur occurs between S2 and S1 Assessing Respiratory - Answer-1. Rate 2. Rhythm 3. Depth 4. Palpate fremitus (vibrations over congestion) 5. Sp02 6. Lip color Heart Assessment - Answer-Aortic Valve- 2nd ICS @ R Sternal Border Pulmonic- 2nd ICS @ L Sternal Border Tricuspid- 4th or 5th ICS @ L sternal border Mitral - 5th ICS @ L Midclavicular Line Vesicle - Answer-Blister, Chickenpox Bruit - Answer-abnormal sound or murmur heard from an organ, gland, or artery. Wheal - Answer-Irregularly shaped, elevated area or superficial localized edema; varies in size (hive, mosquito bite) Scar - Answer-Keloid Fissure - Answer-tear in skinContusion - Answer-Bruise abrasion - Answer-superficial damage to skin exudate - Answer-fluid and dead tissue cells and WBCs @ inflammation site - sanguineous (containing red blood cells) - purulent (containing WBCs and bacteria). excoriation - Answer-damage to surface of skin redness and skin sloughing stuporous vs. comatose - Answer-stuporous- unconscious, can arouse comatose- cannot arouse Anascarca - Answer-generalized edema Ascites - Answer-swollen abdomen Braden Scale - Answer-Shows Risk for Pressure Ulcer Development six subscales: ry perception ure ity 4. mobility tion ion/shear. score ranges from 6 to 23 lower the score = higher risk for pressure ulcer development How to Measure skin Lesion - Answer-ABCD A- asymmetry B- Border irregular C- Color D- diameterMacule - Answer-Flat, nonpalpable change in skin color; smaller than 1 cm ( freckle, petechiae) Papule - Answer-Palpable, circumscribed, solid elevation in skin; smaller than 1 cm ( elevated nevus)