Answer: D) Fine crackles.
Fine crackles are brief, discontinuous, popping lung sounds that are high-pitched.
Crackles, previously termed rales, can be heard in both phases of respiration. Early inspiratory and expiratory crackles are the hallmark of chronic bronchitis. Late inspiratory crackles may mean pneumonia, CHF, or atelectasis. Pleural rubs are discontinuous or continuous, creaking or grating sounds. Because these sounds occur
whenever the patient's chest wall moves, they appear on inspiration and expiration.
Stridor is a loud, high-pitched crowing breath sound heard during inspiration but may also occur throughout the respiratory cycle most notably as a patient worsens.
Stridor is caused by upper airway narrowing or obstruction.
Causes of stridor are pertussis, croup, epiglottis, aspirations.
Wheezes are adventitious lung sounds that are continuous with a musical quality.The proportion of the
respiratory cycle occupied by the wheeze roughly corresponds to the degree of airway obstruction. Wheezes are caused by narrowing of the airways.
Answer: B) Client with COPD whose oxygen saturation is 78%
Airway - what could cause it to be blocked? Trauma, mucus, etc. One nursing dx is ineffective airway clearance.
Breathing - anything having to do with the act of breathing -- respiration rate and depth (ineffective breathing pattern) or gas exchange in the lungs (ineffective gas exchange).
Circulation - anything to do with the vascular system. Think bleeding, cardiac output, dehydration, fluid overload, etc. Decreased cardiac output, fluid volume deficit/excess, risk for bleeding.
Then you go with Maslow's hierarchy for your prioritization. Pain before coping, food before love, etc.
C
The hot/cold theory of health is based on humoral theory; the treatment of disease is based on the
balance of the humors.
Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics.
Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not their physical characteristics.
The four humors of the body include the blood, phlegm, black bile, and yellow bile; the humors regulate basic bodily functions and are
described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors.
The general survey consists of four distinct areas. These areas include:
A. mental status, speech, behavior, and mood and affect.
B. gait, range of motion, mental status, and behavior.
C. physical appearance, body structure, mobility, and behavior.
D. level of
consciousness, personal hygiene, mental status, and physical condition.
D
Functions of the skin include protection, prevention of penetration, perception (of touch, pain, temperature, and pressure), temperature regulation, identification, communication, wound repair, absorption and excretion, and production of vitamin D.
The skin produces vitamin D, not vitamin C.
The basal cell layer of the epidermis forms new skin cells. Melanocytes produce
melanin, which gives brown tones to the skin and hair.
Sebum is produced by the sebaceous glands to lubricate the skin and hair.
B
Facial characteristics of fetal alcohol syndrome include narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia.
Facial characteristics of Down syndrome include upslanting eyes with inner epicanthal folds; flat nasal bridge; small, broad, flat nose; protruding thick tongue; and ear dysplasia.
Facial characteristics of chronic allergies include exhausted face, blue shadows below the eyes, double or single crease on the lower eyelids, central facial pallor, open mouth breathing (malocclusion of the teeth and malformed jaw), and a transverse line on the nose.
Facial characteristics of congenital hypothyroidism include low hairline, hirsute forehead, swollen eyelids, narrow palpebral fissures, widely spaced eyes, depressed nasal bridge, puffy face, thick tongue protruding through
an open mouth, and a dull expression.
C
Myxedema (hypothyroidism) is a deficiency of thyroid hormone. If severe, the symptoms include nonpitting edema or myxedema; a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry coarse hair and eyebrows.
Congenital hypothyroidism is a thyroid deficiency that occurs at an early age; characteristics include low hairline, hirsute forehead, swollen
eyelids, narrow palpebral fissures, widely spaced eyes, depressed nasal bridge, puffy face, thick tongue protruding through an open mouth, and a dull expression.
Scleroderma is a rare connective tissue disease characterized by chronic hardening and shrinking degenerative changes in the skin blood vessels, synovium, and skeletal muscles.
Hashimoto thyroiditis is a condition with excess thyroid hormone production; symptoms include goiter, nervousness, fatigue, weight loss, muscle cramps,
heat intolerance, tachycardia, shortness of breath, excessive sweating, fine muscle tremor, thin silky hair and skin, infrequent blinking, and a staring appearance.
D
Facial characteristics of Parkinson disease include a flat, expressionless face that is masklike with elevated eyebrows, a staring gaze, oily skin, and drooling.
Facial characteristics of acromegaly include an elongated head, a massive face, a prominent nose and lower jaw, a heavy
eyebrow ridge, and coarse facial features.
Facial characteristics of scleroderma include hard, shiny skin on the forehead and cheeks; thin, pursed lips with radial furrowing; absent skinfolds; muscle atrophy of the face and neck; and absence of expression.
Facial characteristics of Cushing syndrome include a plethoric, rounded, "moonlike" face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheeks, and chin.