NUR 6512 FINAL EXAM WITH CORRECT QUESTIONS AND ANSWERS
Varicosity Findings In Pregnant Women - With increasing cardiac output
beginning in the 1st
... [Show More] trimester, the pulse may be more easily palpated, with
an abrupt rise and rapid fall. With increasing blood volume in the second
trimester, jugular a and v waves may be easier to see. JVP should remain
normal. Peripheral edema is a common finding as the pregnancy
progresses. Varicose veins can develop during pregnancy and in the
postpartum period.
Heart Sounds - S1 - Closure of the mitral and tricuspid (AV) Valves,
indicates the beginning of systole. Best heard toward the apex.
S2 - Closure of the aortic and pulmonic (semilunar) Valves, indicates the
end of systole. Best heard in the aortic and pulmonic areas. Higher pitch
and shorter duration.
S3 - Best heard when the patient is in the left lateral decubitus (recumbent)
position. Ventricular Gallup - Ken-Tuck-Y
S4 - Most commonly heard in the older patients, but may be heard at any
age when there is increased resistance to filling because the ventricular
walls have lost compliance. Atrial Gallup - Ten-nes-see
Examination Technique for the Apical Pulse - PMI Point of Maximal Impulse
typically noted at the left 5th intercostal space, midclavicular line in adults,
and 4th intercostal space medial to the nipple in children.
If the apical impulse is more vigorous than expected, characterize it as a
"heave" or "lift." Pg 337
Grading of Heart Murmurs - Grade I - Barely audible in quiet room
Grade II - Quiet but clearly audible
Grade III - Moderately loud
Grade IV - Loud, associated with thrill
Grade V - Very loud, thrill easily palpable
Grade VI - Very loud, audible with stethoscope not in contact with chest,
thrill palpable and visible
Cardiac Examination Findings for Rheumatic Fever - Carditis
Mitral or Aortic Valve becomes stenotic and regurgitant.
Chest Pain
Palpitations
Murmurs of mitral regurgitation and aortic insufficiency
Cardiomegaly
Friction rub of pericarditis
Signs of CHF
Examination Findings of a child with Kawasaki disease - Fever, Conjunctival
Injection, Strawberry Tongue, and Edema of the Hands and Feet.
Lymphadenopathy and Polymorphous Nonvesicular Rashes.
Peripheral Edema - Grading:
1+ Slight Pitting, no visible distortion, disappears rapidly.
2+ A Somewhat Deeper Pit than in 12+, but again no readily detectable
distortion, disappears in 10-15 seconds.
3+ Noticeably Deep Pit that may last more than a minute; dependent
extremity looks fuller and swollen.
4+ Very Deep Pit that lasts as long as 2-5 min; dependent extremity is
grossly distorted.
Ammonia in breath odor - Uremia (ammonia)
Grading of Pulses - 4+ Bounding
3+ Full, Increased
2+ Expected
1+ Diminished, barely palpable
0 Absent, not palpable
Acute Limb Ischemia (ALI) - Stage I - Viable - No sensory impairment - No
motor impairment - Audible Arterial Doppler Signal - Audible Venous Dopler
Signal
Stage IIa - Marginally Threatened - Minimal Sensory Impairment - No Motor
Impairment - Often inaudible Arterial Doppler Signal - Audible Venous
Doppler Signal
Stage IIb - Immediately Threatened - Rest Pain Sensory Impairment - Mild to
moderate Motor Impairment - Inaudible Arterial Doppler Signal - Audible
Venous Doppler Signal
Stage III - Irreversible - Anesthetic Sensory Impairment - Paralytic/rigor
Motor Impairment - Inaudible Arterial Doppler Signal - Inaudible Venous
Doppler Signal
Assessment for Peripheral Arterial Disease - Site of Pain is Distal to the
Narrowing.
Note:
Pulses (strong, weak or possibly absent)
Possible systolic bruits over the arteries that may extend through diastole.
Loss of expected body warmth.
Localized pallor and cyanosis.
Collapsed superficial veins, with delay in venous filling.
Thin, atrophied skin; muscle atrophy. [Show Less]