CCBC NURN155 CORRECT STUDY ANSWERS AND
QUESTIONS SET A+
✔✔Factors that influence temperature - ✔✔- Age
- Diurnal variations
- Exercise
- Hormones
- Stress
- Environment
- Illness
✔✔Tachycardia - ✔✔Rapid heart rate
✔✔Bradycardia - ✔✔Slow heart rate
✔✔Stroke Volume - ✔✔The amount of blood ejected from the heart in one contraction.
✔✔Cardiac Output - ✔✔Heart rate x Stroke volume
✔✔Pulse Characteristics - ✔✔0 no pulse detected
1+ pulse diminished, weak, thready
2+ easily palpable, normal pulse
3+ Full pulse, increased
4+ Strong, bounding pulse
✔✔Factors Affecting Pulse - ✔✔- Sex
- Exercise
- Food
- Stress
- Fever
- Disease
- Blood loss
- Medications
,✔✔Pulse Assessment sites - ✔✔
✔✔Radial Pulse - ✔✔Used most commonly in adults
✔✔Carotid Pulse - ✔✔Closest to heart, use in emergency
Never palpate both sides!
Reflects heart function best
✔✔Apical Pulse - ✔✔Most accurate
Place the stethoscope in the 5th intercostal space to the left of the sternum and slightly
medial of the left mid-clavicular line
✔✔Brachial Pulse - ✔✔Use in infants/children
Auscultated in BP
✔✔Femoral Pulse - ✔✔Used in emergencies
✔✔Popliteal, Posterior Tibial & Dorsalis Pedis Pulse - ✔✔Used to monitor circulation
✔✔Eupnea - ✔✔Normal respirations
✔✔Apnea - ✔✔Absence of breathing
✔✔Tachypnea - ✔✔Rapid breathing
✔✔Bradypnea - ✔✔Abnormally slow breathing
✔✔Cheyne-Stokes - ✔✔Abnormal breathing pattern; periods of dyspnea and apnea
✔✔Factors Affecting Breathing - ✔✔- Age
- Exercise
- Pain
- Stress
- Smoking
- Fever
- Hemoglobin
- Disease
- Medications
- Position
✔✔Pulse Oximetry - ✔✔Oxygen saturation of the hemoglobin
✔✔Pulse Oximetry readings - ✔✔95-100% normal
, 70% of less life threatening
Can detect hypoxemia before cyanosis
✔✔Perfusion - ✔✔Exchange of blood, gases, and fluids between the vessels, tissues
and organ systems.
✔✔Perfusion Pain - ✔✔- Chest Pain: PQRSTU, Acute Coronary Syndrome,
Inflammatory Heart Disorders, Non-cardiac causes
- Leg Pain
✔✔Perfusion History - ✔✔Dyspnea, cough
Fatigue
Cyanosis/Pallor
Edema
Medication - prescription, OTC
Elimination - nocturia, constipation
Sleep Patterns - orthopnea, paroxysmal nocturnal, dyspnea, sleep apnea
Leg pain or cramps
Skin changes
Family Medical History
✔✔Perfusion Personal Habits - ✔✔- Nutrition
- Smoking
- Alcohol
- Exercise
- Drugs
- Stressors and how the patient copes with stress
✔✔Thrill - ✔✔palpable vibration (purring cat)
✔✔Lift (Heave) - ✔✔PMI so strong that it lifts your finger
✔✔Jugular Venous Distension (JVD) - ✔✔Marker of fluid volume
✔✔S1 & S2 - ✔✔LUB DUB (normal heart sound)
✔✔S3 & S4 - ✔✔Extra heart sounds (Dysrhythmias)
✔✔Murmurs - ✔✔Sounds created by abnormal, turbulent flow of blood in the heart
- velocity of blood increases
- viscosity of blood decreases
- structural defects in valves
- unusual openings occur in chambers
✔✔Auscultation Points - ✔✔
QUESTIONS SET A+
✔✔Factors that influence temperature - ✔✔- Age
- Diurnal variations
- Exercise
- Hormones
- Stress
- Environment
- Illness
✔✔Tachycardia - ✔✔Rapid heart rate
✔✔Bradycardia - ✔✔Slow heart rate
✔✔Stroke Volume - ✔✔The amount of blood ejected from the heart in one contraction.
✔✔Cardiac Output - ✔✔Heart rate x Stroke volume
✔✔Pulse Characteristics - ✔✔0 no pulse detected
1+ pulse diminished, weak, thready
2+ easily palpable, normal pulse
3+ Full pulse, increased
4+ Strong, bounding pulse
✔✔Factors Affecting Pulse - ✔✔- Sex
- Exercise
- Food
- Stress
- Fever
- Disease
- Blood loss
- Medications
,✔✔Pulse Assessment sites - ✔✔
✔✔Radial Pulse - ✔✔Used most commonly in adults
✔✔Carotid Pulse - ✔✔Closest to heart, use in emergency
Never palpate both sides!
Reflects heart function best
✔✔Apical Pulse - ✔✔Most accurate
Place the stethoscope in the 5th intercostal space to the left of the sternum and slightly
medial of the left mid-clavicular line
✔✔Brachial Pulse - ✔✔Use in infants/children
Auscultated in BP
✔✔Femoral Pulse - ✔✔Used in emergencies
✔✔Popliteal, Posterior Tibial & Dorsalis Pedis Pulse - ✔✔Used to monitor circulation
✔✔Eupnea - ✔✔Normal respirations
✔✔Apnea - ✔✔Absence of breathing
✔✔Tachypnea - ✔✔Rapid breathing
✔✔Bradypnea - ✔✔Abnormally slow breathing
✔✔Cheyne-Stokes - ✔✔Abnormal breathing pattern; periods of dyspnea and apnea
✔✔Factors Affecting Breathing - ✔✔- Age
- Exercise
- Pain
- Stress
- Smoking
- Fever
- Hemoglobin
- Disease
- Medications
- Position
✔✔Pulse Oximetry - ✔✔Oxygen saturation of the hemoglobin
✔✔Pulse Oximetry readings - ✔✔95-100% normal
, 70% of less life threatening
Can detect hypoxemia before cyanosis
✔✔Perfusion - ✔✔Exchange of blood, gases, and fluids between the vessels, tissues
and organ systems.
✔✔Perfusion Pain - ✔✔- Chest Pain: PQRSTU, Acute Coronary Syndrome,
Inflammatory Heart Disorders, Non-cardiac causes
- Leg Pain
✔✔Perfusion History - ✔✔Dyspnea, cough
Fatigue
Cyanosis/Pallor
Edema
Medication - prescription, OTC
Elimination - nocturia, constipation
Sleep Patterns - orthopnea, paroxysmal nocturnal, dyspnea, sleep apnea
Leg pain or cramps
Skin changes
Family Medical History
✔✔Perfusion Personal Habits - ✔✔- Nutrition
- Smoking
- Alcohol
- Exercise
- Drugs
- Stressors and how the patient copes with stress
✔✔Thrill - ✔✔palpable vibration (purring cat)
✔✔Lift (Heave) - ✔✔PMI so strong that it lifts your finger
✔✔Jugular Venous Distension (JVD) - ✔✔Marker of fluid volume
✔✔S1 & S2 - ✔✔LUB DUB (normal heart sound)
✔✔S3 & S4 - ✔✔Extra heart sounds (Dysrhythmias)
✔✔Murmurs - ✔✔Sounds created by abnormal, turbulent flow of blood in the heart
- velocity of blood increases
- viscosity of blood decreases
- structural defects in valves
- unusual openings occur in chambers
✔✔Auscultation Points - ✔✔
