Maryville NURS 612 Exam 2 Questions and Correct Answers

Inspect the chest without clothes on; 1st assess shape and size; 2nd check for symmetry; 3rd thoracic landmarks; 4th color of skin; 5th check for supernumerary nipples; 6th superficial venous patterns; and 7th observe for rib prominence Thoracic landmarks midline trachea, costal angle, angle of ribs, intercostal spaces, suprasternal notch Symmetry of chest thoracic expansion at costal angle, w/o use of accessory muscles Hx questions for cc of resp issue what is the nature of your cough?; do you produce any sputum?; is your 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 activity? Normal respirations rate 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, not too shallow or too deep Hypopnea term for abnormally shallow respirations Tachypnea term for resp rate greater than 20, but consistent and may occur during hyperventilation; often a symptom of pain Bradypnea term for resp rate less than 12; may indicate neurologic or electrolyte disturbances, infection, or conscious response to protect against the pain of pleurisy or other irritative pneumonia. Can also be 2/2 level of cardio fitness Hyperventilation term for fast and deep, heavy respirations, can be caused by exercise, anxiety, and cns and metabolic diseases Hyperpnea term for abnormally deep respirations Kussmaul respirations deep and mostly rapid respirations, used to describe resp effort of metabolic acidosis Cheyne stokes respirations regular breathing with intervals of apnea by crescendo decrescendo breathing; can be seen in sleeping pts, but mostly pts who are very ill, esp with brain damage