Maryville NURS 612 Exam 2 Questions and Answers
Graded A+
inspect the chest - ANSWER -without bradypnea - ANSWER -term for resp rate
clothes on; 1st assess shape and size; 2nd less than 12; may indicate neurologic or
check for symmetry; 3rd thoracic landmarks; 4th electrolyte disturbances, infection, or conscious
color of skin; 5th check for supernumerary response to protect against the pain of pleurisy or
nipples; 6th superficial venous patterns; and 7th other irritative pneumonia. Can also be 2/2 level
observe for rib prominence of cardio fitness
thoracic landmarks - ANSWER -midline hyperventilation - ANSWER -term for fast
trachea, costal angle, angle of ribs, intercostal and deep, heavy respirations, can be caused by
spaces, suprasternal notch exercise, anxiety, and CNS and metabolic
diseases
symmetry of chest - ANSWER -thoracic
expansion at costal angle, w/o use of accessory hyperpnea - ANSWER -term for abnormally
muscles deep respirations
hx questions for cc of resp issue - kussmaul respirations - ANSWER -deep
ANSWER -What is the nature of your and mostly rapid respirations, used to describe
cough?; Do you produce any sputum?; Is your resp effort of metabolic acidosis
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 cheyne stokes respirations - ANSWER -
activity? regular breathing with intervals of apnea by
crescendo decrescendo breathing; can be seen
in sleeping pts, but mostly pts who are very ill,
normal respirations - ANSWER -rate esp with brain damage
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, biot respirations - ANSWER -irregular
not too shallow or too deep breathing that varies in depth and is interrupted
irregularly by intervals of apnea; associated with
severe and persistent increased intracranial
hypopnea - ANSWER -term for abnormally pressure, resp compromise from drug poisoning,
shallow respirations or brain damage at the medulla and generally
equals poor prognosis
tachypnea - ANSWER -term for resp rate
greater than 20, but consistent and may occur peripheral areas related to respiratory
during hyperventilation; often a symptom of pain assessment - ANSWER -observe the lips
and nails for cyanosis or pallor; lips for pursing;
fingers for clubbing; and alae nasi for flaring
1/7
, Maryville NURS 612 Exam 2 Questions and Answers
Graded A+
pleural thickening, or effusion, massive pulm
edema, or bronchial obstruction. Increased
pleural friction rub - ANSWER -dry, fremitus often coarser or rougher in feel, caused
rubbing, or grating sound; palpable, coarse, by presence of fluids or solid mass within the
grating vibration; usually on inspiration; caused lungs.
by inflammation of the pleural surfaces; think feel
of leather rubbing on leather
7 characteristics of enlarged lymph nodes -
ANSWER -location, size and shape,
thoracic expansion - ANSWER -stand consistency, mobility, discreteness, tenderness,
behind patient and place thumbs along spinal and warmth
process at level of 10th rib, with palms lightly in
contact with the posterolateral surfaces; watch
the thumbs during quiet and deep breathing; loss occipital lymph nodes - ANSWER -lymph
of symmetry = problem on either 1 or both sides. nodes at the base of the skull
crepitus - ANSWER -crackly/crinkly postauricular lymph nodes - ANSWER -
sensation that can be palpated and heard, a lymph nodes over the mastoid process, behind
gentle bubbly feeling; indicates air in the the ear
subcutaneous tissue from a rupture somewhere
in the resp system, or infection with gas
producing organism preauricular lymph nodes - ANSWER -
lymph nodes in front of the ear
palpating the chest and trachea -
ANSWER -palpate the throracic muscles parotid and retropharyngeal lymph nodes -
and skeleton; feeling for pulsations, areas of ANSWER -lymph nodes at the angle of the
tenderness, bulges, depressions, masses, and mandible (tonsillar)
unusual movement
submandibular lymph nodes - ANSWER -
tactile fremitus - ANSWER -palpable lymph nodes halfway between the angle and tip
vibration of the chest wall that results from of the mandible
speech or other verbalizations. best felt
posteriorly and laterally at the level of the
bifurcation of the bronchi; have patient say "99" submental lymph nodes - ANSWER -lymph
while you palpate with palmer surface of fingers nodes in the midline behind the tip of the
or ulner aspect of the hand; use firm, light touch mandible
abnormal tactile fremitus - ANSWER - superficial cervical lymph nodes -
decreased of absent fremitus may be caused by ANSWER -lymph nodes at the
excess air in lungs or may indicate emphysema,
2/7
Graded A+
inspect the chest - ANSWER -without bradypnea - ANSWER -term for resp rate
clothes on; 1st assess shape and size; 2nd less than 12; may indicate neurologic or
check for symmetry; 3rd thoracic landmarks; 4th electrolyte disturbances, infection, or conscious
color of skin; 5th check for supernumerary response to protect against the pain of pleurisy or
nipples; 6th superficial venous patterns; and 7th other irritative pneumonia. Can also be 2/2 level
observe for rib prominence of cardio fitness
thoracic landmarks - ANSWER -midline hyperventilation - ANSWER -term for fast
trachea, costal angle, angle of ribs, intercostal and deep, heavy respirations, can be caused by
spaces, suprasternal notch exercise, anxiety, and CNS and metabolic
diseases
symmetry of chest - ANSWER -thoracic
expansion at costal angle, w/o use of accessory hyperpnea - ANSWER -term for abnormally
muscles deep respirations
hx questions for cc of resp issue - kussmaul respirations - ANSWER -deep
ANSWER -What is the nature of your and mostly rapid respirations, used to describe
cough?; Do you produce any sputum?; Is your resp effort of metabolic acidosis
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 cheyne stokes respirations - ANSWER -
activity? regular breathing with intervals of apnea by
crescendo decrescendo breathing; can be seen
in sleeping pts, but mostly pts who are very ill,
normal respirations - ANSWER -rate esp with brain damage
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, biot respirations - ANSWER -irregular
not too shallow or too deep breathing that varies in depth and is interrupted
irregularly by intervals of apnea; associated with
severe and persistent increased intracranial
hypopnea - ANSWER -term for abnormally pressure, resp compromise from drug poisoning,
shallow respirations or brain damage at the medulla and generally
equals poor prognosis
tachypnea - ANSWER -term for resp rate
greater than 20, but consistent and may occur peripheral areas related to respiratory
during hyperventilation; often a symptom of pain assessment - ANSWER -observe the lips
and nails for cyanosis or pallor; lips for pursing;
fingers for clubbing; and alae nasi for flaring
1/7
, Maryville NURS 612 Exam 2 Questions and Answers
Graded A+
pleural thickening, or effusion, massive pulm
edema, or bronchial obstruction. Increased
pleural friction rub - ANSWER -dry, fremitus often coarser or rougher in feel, caused
rubbing, or grating sound; palpable, coarse, by presence of fluids or solid mass within the
grating vibration; usually on inspiration; caused lungs.
by inflammation of the pleural surfaces; think feel
of leather rubbing on leather
7 characteristics of enlarged lymph nodes -
ANSWER -location, size and shape,
thoracic expansion - ANSWER -stand consistency, mobility, discreteness, tenderness,
behind patient and place thumbs along spinal and warmth
process at level of 10th rib, with palms lightly in
contact with the posterolateral surfaces; watch
the thumbs during quiet and deep breathing; loss occipital lymph nodes - ANSWER -lymph
of symmetry = problem on either 1 or both sides. nodes at the base of the skull
crepitus - ANSWER -crackly/crinkly postauricular lymph nodes - ANSWER -
sensation that can be palpated and heard, a lymph nodes over the mastoid process, behind
gentle bubbly feeling; indicates air in the the ear
subcutaneous tissue from a rupture somewhere
in the resp system, or infection with gas
producing organism preauricular lymph nodes - ANSWER -
lymph nodes in front of the ear
palpating the chest and trachea -
ANSWER -palpate the throracic muscles parotid and retropharyngeal lymph nodes -
and skeleton; feeling for pulsations, areas of ANSWER -lymph nodes at the angle of the
tenderness, bulges, depressions, masses, and mandible (tonsillar)
unusual movement
submandibular lymph nodes - ANSWER -
tactile fremitus - ANSWER -palpable lymph nodes halfway between the angle and tip
vibration of the chest wall that results from of the mandible
speech or other verbalizations. best felt
posteriorly and laterally at the level of the
bifurcation of the bronchi; have patient say "99" submental lymph nodes - ANSWER -lymph
while you palpate with palmer surface of fingers nodes in the midline behind the tip of the
or ulner aspect of the hand; use firm, light touch mandible
abnormal tactile fremitus - ANSWER - superficial cervical lymph nodes -
decreased of absent fremitus may be caused by ANSWER -lymph nodes at the
excess air in lungs or may indicate emphysema,
2/7
