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MARYVILLE NURS 612 ACTUAL EXAM 2 NEWSET VERSION -
2025/2026- QUESTIONS AND VERIFIED ANSWERS (100%
SUCCEESS)
vesicular breath sounds low pitch, low intensity; heard over healthy lung tissue bronchovesicular breath sounds heard over major bronchi; medium pitch and moderate intensity bronchial breath sounds high pitch and high intensity; heard over trachea hamman sign lung sound: mediastinal crunch; greater variety of sounds loud crackles, clicking, and gurgling sounds over pericardium; they are synchronous with the heart beat and not particularly with respirations; more pronounced toward end of expiration and easiest to hear when pt leans on the left of lies on the left side; found with mediastinal emphysema
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 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
dry, rubbing, or grating sound; palpable, coarse, grating vibration; usually on inspiration; caused by inflammation of the pleural surfaces; think feel of leather rubbing on leather thoracic expansion stand behind patient and place thumbs along spinal process at level of 10th rib, with palms lightly in contact with the posterolateral surfaces; watch the thumbs during quiet and deep breathing; loss of symmetry = problem on either 1 or both sides. crepitus crackly/crinkly sensation that can be palpated and heard, a gentle bubbly feeling; indicates air in the subcutaneous tissue from a rupture somewhere in the resp system, or infection with gas producing organism palpating the chest and trachea palpate the throracic muscles and skeleton; feeling for pulsations, areas of tenderness, bulges, depressions, masses, and unusual movement tactile fremitus palpable vibration of the chest wall that results from speech or other verbalizations. best felt posteriorly and laterally at the level of the bifurcation of the bronchi; have patient say "99" while you palpate with palmer surface of fingers or ulner aspect of the hand; use firm, light touch
abnormal tactile fremitus decreased of absent fremitus may be caused by excess air in lungs or may indicate emphysema, pleural thickening, or effusion, massive pulm edema, or bronchial obstruction. Increased fremitus often coarser or rougher in feel, caused by presence of fluids or solid mass within the lungs. 7 characteristics of enlarged lymph nodes location, size and shape, consistency, mobility, discreteness, tenderness, and warmth occipital lymph nodes lymph nodes at the base of the skull postauricular lymph nodes lymph nodes over the mastoid process, behind the ear preauricular lymph nodes lymph nodes in front of the ear
supraclavicular area lymph nodes lymph nodes that you must probe deeply in the angle formed by the clavicle and sternocleidomastoid muscle, common sites for metastatic disease axillary lymph nodes lymph nodes found by supporting pt's forearm w/ your non exam arm; and by bringing the palm of your exam hand into the axilla. Let the soft tissues roll b/w your fingers and the pt's chest wall and muscles. Rotate your fingertips and palm to feel for the nodes. epitrochlear lymph nodes lymph nodes found by supporting pt's arm in one hand as you explore with your other hand in the groove of the elbow b/w the triceps and biceps muscles inguinal lymph nodes lymph nodes found by having the patient lie supine, feel for the superior inguinal lymph nodes (femoral) that lie close to the surface over the inguinal canals. Assess the inferior superficial inguinal lymph nodes which lie deeper in the groin 6 characteristics of skin assessment color, uniformity, thickness, symmetry, hygiene, and lesions
popliteal lymph nodes lymph nodes found by flexing the supine pt's knee and wrapping your hand around it and palpate the fossa with your fingers 5 characteristics of the skin moisture, temperature, texture, turgor, and mobility documentation of skin lesion size, shape, color, texture, elevation, depression, attachment, exudate, configuration, location and distribution, subtle details, transillumination, and shine a wood's lamp on it nevi normal skin lesions macule a flat, circumscribed area that is change in color of skin, less than 1 cm (freckles, flat moles, measles) papule
elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter (neoplasms, benign tumor, lipoma) vesicle elevated, circumscribed, superficial not into the dermis; filled with serous fluid; less than 1 cm in diameter (varicella, herpes zoster) bulla vesicle greater than 1 cm in diameter (blister, pemphigus vulgaris) pustule elevated, superficial lesion; similar to a vesicle but filled with purulent fluid (impetigo, acne) cyst elevated, circumscribed encapsulated lesion; in dermis or subcutaneous layer, filler with liquid or semisolid material (sebaceous cyst or cystic acne) telangiectasia fine, irregular, red lines; produced by capillary dilation (rosacea)
scale heaped up, keratinized cells; flaky skin; irregular; thick and thin; dry or oily; variation in size (flaking of the skin with seborrheic dermatitis, following drug rxn, dry skin) lichenification rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surface of extremity (chronic dermatitis) keloid irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing (keloid formation post surgery) scar thin to thick fibrous tissue what replaces normal skin following injury or laceration to the dermis (healed wound or surgical incision) excoriation loss of the epidermis; linear hollowed out, crusted area (scabies, abrasion or scratch)
annular round, active margins with central clearing (tinea corporis, sarcoidosis) examining the hair palpate its texture, scalp hair may be coarse or fine, and curly or straight. Should be shiny, smooth, and resilient 3 characteristics of hair color, distribution, and quantity 6 characteristics of nails color, length and condition, edges, configuration, symmetrical, and clean/smooth/neat 4 characteristics nail palpation texture, firmness, thickness, and adherence basal cell carcinoma cancer that arises in the basal layer of the epidermis; shiny nodule that is pearly or translucent; may be pink, red, black, white, tan or brown; occurs on exposed
parts (face, ears, neck, scalp); persistent sore or lesion that has not healed; may have crusting, bleed, or itchy; most common type squamous cell carcinoma malignant tumor arises in the epithelium; occurs in sun exposed areas; persistent sore that has not healed; may have crusting or bleeding; elevated, wart-like growth with central depression; 2nd most common malignant melanoma lethal skin cancer; melanocytes migrate into the skin, eye, CNS, and mucous; less than half develop from nevi; exact cause unknown; new mole or preexisting mole that has changed or is changing; ABCDE changes in moles 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 ABCDE changes in moles
vocal resonance ask pt to say numbers "99" or words, transmitted sounds are usually muffled and indistinct and are best heard medially bronchophony greater clarity and increased loudness of spoken sounds egophony when intensity of the spoken voice is increased and there is a nasal quality whispered pectoriloquy extreme bronchophony; occurs with presence of consolidation; a whisper can be heard clearly and intelligently with a stethoscope 6 characteristics of inspecting head and face head position, facial features and shape/symmetry, tics, shape and unusual features, skull, and scalp tics spasmodic muscular contractions of the face, head, and neck; may be associated with pressure or degenerative changes to facial nerves or tourette syndrome
5 areas to palpate for head and neck skull, hair, temporal arteries, temporomandibular joint, and salivary glands hypercalcemia on percussion of the masseter muscle, facial spasms are associated with ..... vascular anomaly on auscultation of the temporal region, over the eyes and below the occiput, a bruit suggests a .... cerebral aneurysm pt's with diplopia, a bruit or blowing sounds over the orbit are rarely heard, and may suggest an expanding ..... 6 characteristics of neck inspection symmetry; trachea alignment; anterior & posterior triangles; fullness at the base ; look for abnormalities ; and jugular vein distention & carotid artery prominence
shotty lymph nodes small, moveable, discrete, nodes that feel like BBs or buckshot under the skin; generally clinically insignificant and usually represent enlargement of lymph nodes following a viral infection vesicular breath sounds low pitch, low intensity; heard over healthy lung tissue bronchovesicular breath sounds heard over major bronchi; medium pitch and moderate intensity bronchial breath sounds high pitch and high intensity; heard over trachea hamman sign lung sound: mediastinal crunch; greater variety of sounds loud crackles, clicking, and gurgling sounds over pericardium; they are synchronous with the heart beat and not particularly with respirations; more pronounced toward end of expiration and easiest to hear when pt leans on the left of lies on the left side; found with mediastinal emphysema
