NR 302 Final Exam
Actual Diagnosis related to (R/T) ________(Related Factors) as evidenced by (AEB) ________ (Defining
Characteristics) - ANSWER: Actual Dx
Risk for __________as evidenced by _________ (Risk Factors). - ANSWER: Risk
Readiness for __________as evidenced by "_________" (Defining characteristics). - ANSWER: Readiness
chronic hyper-reactive condition. Obstruction. Wheezing. Dyspnea, increased RR, use of accessory muscles,
anxiety, prolonged expiration.
Palpation- decreased tactile fremitus
Percussion- resonance. Hyperresonance with chronic.
Auscultation- wheezing, decreased voice sounds. Severe; no breath sounds. - ANSWER: Asthma
obstruction of airflow. Increased RR, dyspnea, cyanosis, trachea shift to affected side in severe cases.
Palpation- lack of tactile fremitus. decreased lung expansion on affected side
Percussion- dullness over affected area
Auscultate- absent or diminished but normal breath sounds bilaterally. - ANSWER: Atelectasis
inflammation of tracheobronchial tree. Early morning, congested, chronic productive cough. White or clear
sputum. Wheezes or rhonchi. Dyspnea, tachypnea, use of accessory muscles. - ANSWER: Chronic Bronchitis
COPD. Obstruction of the alveoli. Tripod posture. Use of accessory muscles. Cyanosis. Clubbing of fingers.
Pursed lip breathing. SOB on exertion.
Palpation- Absent or decreased tactile fremitus. Decreased chest expansion.
Percussion- Hyper-resonance.
Auscultate- diminished but normal breath sounds bilaterally, decreased vesicular sounds, wheezing. -
ANSWER: Emphysema
>90 costal angle. Barrel chest AP=T. ↓ Tactile fremitus palp. Tripod posture. Use of accessory muscles.
Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB on exertion. - ANSWER: COPD
,infection of the alveoli, Consolidation. Tachypnea, congested, hacking, productive cough, chills, chest pain
with breathing. Mucosal edema. Sputum- rust.
Palpation- increased tactile fremitus. Decreased chest expansion on affected side.
Percussion- dullness over affected area.
Auscultation- Egophony changes e to a. Clear Whispered pectoriloguy & bronchophony. Bronchial breath
sounds and crackles. - ANSWER: Lobular Pneumonia
fluid in the pleural space. Dyspnea. Tracheal shift to unaffected side.
Palpation- Absent or decreased tactile fremitus. decreased chest expansion side affected.
Percussion- Dullness
Auscultation- unilateral lung sounds. Decreased/absent breath/voice sounds. Pleural rub. - ANSWER: Pleural
effusion
air in pleural space, collapse of the lung. Tachypnea, tracheal shift to unaffected side.
Palpation- Decreased Tactile fremitus. Unilateral decrease or delay in respiratory expansion.
Percussion- Hyper-resonance
Auscultation- unilateral of normal lung sounds. Decreased/absent breath/voice sounds. - ANSWER:
Pneumothorax
Increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema
of the bronchial mucosa. Pulmonary congestion.
Increased respiratory rate, shortness of breath (especially on exertion), orthopnea, peripheral edema, pallor.
S3. Hypertrophy. Dry cough.
Palpation- Normal tactile fremitus. Skin cool and clammy.
Percussion- Resonance.
Auscultation-Normal breath sounds and voice sounds. Wheezes or crackles at the bases of the lungs. -
ANSWER: Congestive heart failure
lung symptoms. 1st Fatigue. Pink frothy sputum. Pulmonary edema. Hypoxia. SOB, crackles/rales, cough,
orthopnea, anxiety, confusion, PND. S3 - ANSWER: ◦ Left-sided CHF
, peripheral symptoms. Skin pale, gray, or cyanotic; nausea, vomiting; pitting edema, peripheral/bilateral
edema, ascites, JVD, HJR, weak pulse, cool moist skin, decreased urine output, increased B.P., weight gain,
liver congestion. Cor Pulmonale - ANSWER: Rt CHF
discontinuous, intermittent, non-musical, and brief. C-collapsed or fluid-filled alveoli open. end inspiration, do
not clear w cough. - ANSWER: Crackles/Rales
soft, high pitched, and very brief. - ANSWER: Fine rales
louder, moist, lower in pitch, longer, bubbling. - ANSWER: Coarse rales/crackles
inspiration/expiration when severe. continuous high pitched with a shrill quality. C- blocked air flow; asthma,
infection, foreign body obstruction. - ANSWER: Wheezes (sibilant)
Expiration/ inspiration. Change/disappear w cough. Continuous low pitched with a snoring, rattling. Fluid-
blocked airways. - ANSWER: Rhonchi (sonorous)
inspiration. Loud high pitched crowing heard without stethoscope. Obstructed upper airways. - ANSWER:
Stridor
inhalation/exhalation. Low pitched grating, rubbing, pleural inflammation - ANSWER: Friction rub
narrowing of the aortic valve. Rheumatic heart DX, atherosclerosis, congential. - ANSWER: Aortic stenosis
backflow of blood from lft ventricle into left atrium. Rheumatic fever, MI. - ANSWER: Mitral regurgitation
Dx of myocardium.
Dilated or congestive (CHF, MI, alcohol, pregnancy)
Hypertrophic (inherited)
Restrictive (connective tissue diseases, cancers) - ANSWER: Cardiomyopathy
↓ myocardial oxygen supply to demand. ^30-90 min, permanent damage. - ANSWER: Myocardial ischemia
Actual Diagnosis related to (R/T) ________(Related Factors) as evidenced by (AEB) ________ (Defining
Characteristics) - ANSWER: Actual Dx
Risk for __________as evidenced by _________ (Risk Factors). - ANSWER: Risk
Readiness for __________as evidenced by "_________" (Defining characteristics). - ANSWER: Readiness
chronic hyper-reactive condition. Obstruction. Wheezing. Dyspnea, increased RR, use of accessory muscles,
anxiety, prolonged expiration.
Palpation- decreased tactile fremitus
Percussion- resonance. Hyperresonance with chronic.
Auscultation- wheezing, decreased voice sounds. Severe; no breath sounds. - ANSWER: Asthma
obstruction of airflow. Increased RR, dyspnea, cyanosis, trachea shift to affected side in severe cases.
Palpation- lack of tactile fremitus. decreased lung expansion on affected side
Percussion- dullness over affected area
Auscultate- absent or diminished but normal breath sounds bilaterally. - ANSWER: Atelectasis
inflammation of tracheobronchial tree. Early morning, congested, chronic productive cough. White or clear
sputum. Wheezes or rhonchi. Dyspnea, tachypnea, use of accessory muscles. - ANSWER: Chronic Bronchitis
COPD. Obstruction of the alveoli. Tripod posture. Use of accessory muscles. Cyanosis. Clubbing of fingers.
Pursed lip breathing. SOB on exertion.
Palpation- Absent or decreased tactile fremitus. Decreased chest expansion.
Percussion- Hyper-resonance.
Auscultate- diminished but normal breath sounds bilaterally, decreased vesicular sounds, wheezing. -
ANSWER: Emphysema
>90 costal angle. Barrel chest AP=T. ↓ Tactile fremitus palp. Tripod posture. Use of accessory muscles.
Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB on exertion. - ANSWER: COPD
,infection of the alveoli, Consolidation. Tachypnea, congested, hacking, productive cough, chills, chest pain
with breathing. Mucosal edema. Sputum- rust.
Palpation- increased tactile fremitus. Decreased chest expansion on affected side.
Percussion- dullness over affected area.
Auscultation- Egophony changes e to a. Clear Whispered pectoriloguy & bronchophony. Bronchial breath
sounds and crackles. - ANSWER: Lobular Pneumonia
fluid in the pleural space. Dyspnea. Tracheal shift to unaffected side.
Palpation- Absent or decreased tactile fremitus. decreased chest expansion side affected.
Percussion- Dullness
Auscultation- unilateral lung sounds. Decreased/absent breath/voice sounds. Pleural rub. - ANSWER: Pleural
effusion
air in pleural space, collapse of the lung. Tachypnea, tracheal shift to unaffected side.
Palpation- Decreased Tactile fremitus. Unilateral decrease or delay in respiratory expansion.
Percussion- Hyper-resonance
Auscultation- unilateral of normal lung sounds. Decreased/absent breath/voice sounds. - ANSWER:
Pneumothorax
Increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema
of the bronchial mucosa. Pulmonary congestion.
Increased respiratory rate, shortness of breath (especially on exertion), orthopnea, peripheral edema, pallor.
S3. Hypertrophy. Dry cough.
Palpation- Normal tactile fremitus. Skin cool and clammy.
Percussion- Resonance.
Auscultation-Normal breath sounds and voice sounds. Wheezes or crackles at the bases of the lungs. -
ANSWER: Congestive heart failure
lung symptoms. 1st Fatigue. Pink frothy sputum. Pulmonary edema. Hypoxia. SOB, crackles/rales, cough,
orthopnea, anxiety, confusion, PND. S3 - ANSWER: ◦ Left-sided CHF
, peripheral symptoms. Skin pale, gray, or cyanotic; nausea, vomiting; pitting edema, peripheral/bilateral
edema, ascites, JVD, HJR, weak pulse, cool moist skin, decreased urine output, increased B.P., weight gain,
liver congestion. Cor Pulmonale - ANSWER: Rt CHF
discontinuous, intermittent, non-musical, and brief. C-collapsed or fluid-filled alveoli open. end inspiration, do
not clear w cough. - ANSWER: Crackles/Rales
soft, high pitched, and very brief. - ANSWER: Fine rales
louder, moist, lower in pitch, longer, bubbling. - ANSWER: Coarse rales/crackles
inspiration/expiration when severe. continuous high pitched with a shrill quality. C- blocked air flow; asthma,
infection, foreign body obstruction. - ANSWER: Wheezes (sibilant)
Expiration/ inspiration. Change/disappear w cough. Continuous low pitched with a snoring, rattling. Fluid-
blocked airways. - ANSWER: Rhonchi (sonorous)
inspiration. Loud high pitched crowing heard without stethoscope. Obstructed upper airways. - ANSWER:
Stridor
inhalation/exhalation. Low pitched grating, rubbing, pleural inflammation - ANSWER: Friction rub
narrowing of the aortic valve. Rheumatic heart DX, atherosclerosis, congential. - ANSWER: Aortic stenosis
backflow of blood from lft ventricle into left atrium. Rheumatic fever, MI. - ANSWER: Mitral regurgitation
Dx of myocardium.
Dilated or congestive (CHF, MI, alcohol, pregnancy)
Hypertrophic (inherited)
Restrictive (connective tissue diseases, cancers) - ANSWER: Cardiomyopathy
↓ myocardial oxygen supply to demand. ^30-90 min, permanent damage. - ANSWER: Myocardial ischemia
