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1. The nurse is teaching a mother whose daughter has iron deficiency anemia.The nurse determines the parent understood the dietary modifications, if she selects? a) Bread and coffee b) Fish and Pork meat c) Cookies and milk d) Oranges and green leafy vegetables 2. Which of the following is the most common clinical manifestation of G6PD following ingestion of aspirin? a) Kidney failure b) Acute hemolytic anemia c) Hemophilia A d) Thalassemia 3. The nurse assesses a client with an ileostomy for possible development of which of the following acid-base imbalances? a) Respiratory acidosis b) Metabolic acidosis c) Metabolic alkalosis d) Respiratory alkalosis 4. The nurse anticipates which of the following responses in a client who develops metabolic acidosis. a) Heart rate of 105 bpm b) Urinary output of 15 ml c) Respiratory rate of 30 cpm d) Temperature of 39 degree Celsius 5. A client has a phosphorus level of 5.0mg/dL. The nurse closely monitors the client for? a) b) c) d) Signs of tetany Elevated blood glucose Cardiac dysrhythmias Hypoglycemia 6. A nurse is caring for a child with pyloric stenosis. The nurse would watch out for symptoms of? a) Vomiting large amounts b) Watery stool c) Projectile vomiting d) Dark-colored stool 7. The nurse responder finds a patient unresponsive in his house. Arrange steps for adult CPR. a) Assess consciousness b) Give 2 breaths c) Perform chest compression d) Check for serious bleeding and shock e) Open patient’s airway f) Check breathing ___, ___, ___, ___, ___, ___ A nurse is going to administer 500mg capsule to a patient. The nurse plans to frequently assess a post-thyroidectomy patient for? a) Polyuria b) Hypoactive deep tendon reflex c) Hypertension d) Laryngospasm 11. Which of the following has mostly likely occurred when there is continuous bubbling in the water seal chamber of the closed chest drainage system? a) The connection has been taped too tightly b) The connection tubes are kinked c) Lung expansion d) Air leak in the system 9. Which if the following young adolescent and adult male clients are at most risk for testicular cancer? a) Basketball player who wears supportive gear during basketball games b) Teenager who swims on a varsity swim team c) 20-year-old with undescended testis d) Patient with a family history of colon cancer 10. bowlegs and slightly large head.) B.) 13. The nurse concludes? a) The child appears to be a normal toddler b) The child is developmentally delayed c) The child is malnourished d) The child’s large head may have neurological problems. An 18-month-old baby appears to have a rounded belly. An appropriate instruction to be included in the discharge teaching of a patient following a spinal fusion is? a) Don’t use the stairs b) Don’t bend at the waist c) Don’t walk for long hours d) Swimming should be avoided .) C. 12.8.) D. Which is the correct route? A. ) B. A nurse is going to administer ear drops to a 4-year-old child.14. What is the correct way of instilling the medicine after tilting the patient’s head sidewards? a) Pull the pinna back then downwards b) Pull the pinna back then upwards c) Pull the pinna up then backwards d) Pull the pinna down then backwards 18.) 20. A pregnant woman is admitted for pre-eclampsia. Which among the following could be the reason? a) The mouth is still too small b) The object may be pushed deeper into the throat c) Sharp fingernails might injure the victim d) The infant might bite . the instructor said that blind finger sweeping is not advisable for infants. A nursing student was intervened by the clinical instructor if which of the following is observed? a) Inserting a nasogastric tube b) Positioning the infant in a ―sniffing ―position c) Suctioning first the mouth. Choose amongst the options illustrated below that best describes the angle for an intradermal injection? A.) C. The nurse would include in the health teaching that magnesium will be part of the medical management to accomplish the following? a) b) c) d) Control seizures promote renal perfusion To decrease sustained contractions Maintain intrauterine homeostasis 17. what is the best action to be taken? a) Apply ice over the injection site b) Administer drug at a 45 degree angle c) Use a 24-gauge-needle d) Use the z-track technique 15. During a basic life support class. What should a nurse do prior to taking the patient’s history? a) Offer the patient a glass of water b) Establish rapport c) Ask the patient to disrobe and put on gown d) Ask pertinent information for insurance purposes 16. then the nose d) Squeezing the bulb syringe to suction mouth 19. A nurse is preparing to give an IM injection of Iron Dextran that is irritating to the subcutaneous tissue.) D. To prevent irritation to the tissue. 21.The doctor ordered 1 pack of red blood cells (PRBC) to be transfused to a patient. The expected yet negative (harmful ) result for posthemodialysis is a decrease in? a) Creatinine b) BUN c) Phosphorus d) Red blood cell count 27. The IV tubing appropriate for blood transfusion comes with? a) Air vent b) Microdrip chamber c) In-line filter d) Soluset 26. A nurse enters a room and finds a patient lying on the floor. The senior nurse should intervene if the new nurse? . Which priority action should the nurse do first? a) Administer morphine sulfate intravenously b) Initiate venous access by performing venipunture c) Administer oxygen via nasal cannula d) Complete physical assessment and patient history 23. Several patients from a reported condominium fire incident were rushed to the emergency room. Which immunization is a priority for a 72 -yearold patient? a) Hepatitis A vaccine b) Hepatitis B vaccine c) Rotavirus Vaccine d) Pneumococcal Vaccine 24. A new nurse is administering an enema to a patient. A patient with complaints of chest pain was rushed to the emergency department. reports hoarseness of the voice b) A 28-year-old man with burns on all extremities c) A 4-year-old child who is crying inconsolably and reports severe headache d) A 40-year-old woman with complaints of severe pain on the left thigh 25. The nurse prepares the proper IV tubing. with burns on the face and chest. A patient was brought to the emergency room after she fell down the stairs. Which of the following actions should the nurse perform first? a) Call for help b) Establish responsiveness of patient c) Ask the patient what happened d) Assess vital signs 22. Which of the following is the best indicator for increased intracranial pressure in head and spinal injury? a) Inability to move extremities b) Decreased respiratory rate c) Increase in pulse and blood pressure d) Decrease level of consciousness 28. Which should the nurse attend to first? a) A 15-year-old girl. A rehab nurse reviews a post-stroke patient’s immunization history. Which of the following instructions should the nurse include in the health teaching? Select all that apply a) Corticosteroid medication is part of the treatment b) Include milk in the diet c) Aspirin should be administered d) Antidiarrheal medication can help .a) Hangs the enema bag 18 inches above the anus b) Positions the client on the right side c) Advances the catheter 4 inches into the anal canal d) Lubricates 4 inches of the catheter tip 29. A 30-year-old client is admitted with inflammatory bowel syndrome (Crohn’s disease). The medication nurse is going to give a patient his morning medications. What is the primary action a nurse should do before administering the medications? a) Provide privacy b) Raise head of the bed c) Give distilled water d) Check client’s identification bracelet 30. ) Answer: D Continuous bubbling seen in water-seal bottle/ chamber indicates an air leak or loose connection. B. 9. check for serious bleeding. Next. Salicylates such as Aspirin damages plasma membranes of erythrocytes. tremors. Undescended testis is also one major risk for testicular cancer. Patients with metabolic acidosis have high respiratory rate. E. 11. respiratory system will try to compensate metabolic acidosis. along with lifting more than 10 lbs. 7. C. Oranges are good sources of vitamin C that enhances iron absorption in the small intestines. and seizures.) Answer: C Initially. including a decrease in urine output.) Answer: D 13. The nurse should first assess consciousness of the patient. 15. The head still appears somewhat large in proportion from the rest of the body. remember AB-CABS. open patient’s airway to check for breathing.) Answer: A Normal phosphorus level is 2.) Answer: B Lower GI fluids are alkaline in nature and can be lost via ileostomy. and air is sucked continuously into the closed chest drainage system.5 – 4. A-airway B-breathing normally? − C-chest compression A-airway open B-breathing for patient S-serious bleeding.5 mg/dL .) Answer: A. Sitting.) Answer: B Establishing rapport is a way to gain trust that will lead for a patient to relax.) Answer: D Dark green leafy vegetables are good sources of iron. 6. 16. For children below 3 years of age. When there is no breathing. Thus.) Answer: D Z-track technique is used to administer drugs especially irritating to the subcutaneous tissue. and spinal injury. 14. Finally. spinal injury. 3. results to metabolic acidosis. shock. loss of HCO3. Bending and twisting at the waist should be avoided. lying. D In accordance with the new guidelines.) Answer: A It’s normal for a toddler to have bowlegs and a protruding belly. 2. constipation.1. 4.) Answer: C Ear canal of children ages 3years and above can be straightened by pulling the pinna up then backwards. . Client should be assessed for tetany which is a prominent symptom of hypocalcemia. and signs of dehydration. 8. 17.) Answer: C Clinical manifestations of pyloric stenosis include projectile vomiting. and gentle swimming is allowed. 10. walking. F.) Answer: C Testicular cancer is most likely to affect males in late adolescence. Magnesium Sulfate is the drug of choice to prevent seizures in pre-eclampsia and eclampsia. 12. leading to hemolytic anemia.) Answer: B There is 6-8 months activity restriction following a spinal fusion.The level reflects hyperphosphatemia which is inversely proportional to calcium. standing. Laryngospasm is one of the clinical manifestations of tetany. shock. do the cycle of care over. certain medications or chemicals. This method promotes absorption of the drug by preventing drug leakage into the subcutaneous layer. normal stair climbing. 5. an indicator of hypocalcemia.) Answer: A Low magnesium (hypomagnesemia) produces clinical manifestations like increased reflexes.) Answer: D Hypocalcemia occurs when there is accidental removal or destruction of parathyroid tissue during surgical removal of the thyroid gland. immediately perform chest compression then give 2 breaths. irritability.) Answer: B Individuals with G6PD may exhibit hemolytic anemia when exposed to infection. the ear canal can be straightened by pulling the pinna down then backwards. You can get more insights and information from a patient when rapport is established. ) Answer: D Recall the 12 Rights of administration.) Answer: C An in-line filter is required for blood transfusions. Maintaining an airway patency is the main concern. Checking the patient’s name is critical for client -safety. 27.) Answer: B 20. Those with Crohn’s disease are mostly lactose intolerant. 29.) Answer: D Negative outcome: Hemodialysis decreases red blood cell count which worsens anemia. have higher risk for serious pneumococcal infection and likely have low immunity.) Answer: A Burns on the face and neck can cause swelling of the respiratory mucosa that can lead to airway obstruction manifested by hoarseness of voice and difficulty in breathing. thus.) Answer: A Infants are nose breathers. 23.) Answer: D Decrease in level of consciousness and headache are early signs of increase in intracranial pressure (ICP). The appropriate position is left lateral to facilitate flow of enema by gravity into the colon. (2) is incorrect. 24. A gastric tube may be inserted to facilitate lung expansion and stomach decompression.) Answer: A . . Chest pain is caused by insufficient myocardial oxygenation. because RBCs are lost in dialysis from anticoagulation during the procedure.) Answer: D Pneumococcal Vaccine is a priority immunization for the elderly. making breathing difficult for the infant. 19. 21. 28. Altered level of consciousness is the most common symptom that indicates a deficit in brain function. abdominal pain. D Crohn’s disease is a chronic inflammation of the colon with symptoms of diarrhea.) Answer: B First step in cardiopulmonary resuscitation (CPR) is assessing responsiveness of the patient. 26.18. so choice no. Corticosteroid is a treatment for Crohn’s disease.) Answer: C Priority nursing action is to administer oxygen to patients with chest pain. ages 65 years old and above. This is administered every 5 years. 25. and from residual blood that is left in the dialyzer. 30.) Answer: B Blind finger sweeps are not recommended in all CPR cases especially for infants and children because the foreign object may be pushed back into the airway. Antidiarrheal can give relief to diarrheal episodes.) Answer: B Recall the anatomy of the colon. 22. Aspirin should be avoided as it can worsen inflammation. and weight loss. Seniors. but not a nasogastric tube as it can occlude the nare. fluid-filled or solid with the use of audible sounds and palpable vibrations being produced. masses. tenderness. size. mental alertness. moisture. cranial nerve function. Observe for skin color. sex. nutritional state. gross visual fields by donfrontation. Palpate skin for temperature. swelling and masses. hair distribution. Be highly sensitive to visual clues. Respiration – note for the rhythm. discharges. pigment. consistency of the cartilage. vesicles. breath sounds and depth of breathing. evidence of pain. Auscultation – Use stethoscope to augment the sense of hearing. Assess the mental status. Examine hearing by mechanical tests such as whisper or watch tic-tac test. sclera and iris for color. 3. Check for the number. Palpate globes through closed lids for the tenderness and tension. Nose and Sinuses – Inspect for general deformity. 4. weak. color of mucous membranes. airway patency. color of the mucus membranes and the turbinates for swelling. lid margins for scaling. palpebral fissures for width and symmetry. lesions. scars. Peripheral Circulation – Palpate for jugular vein distention and pulsations. color. duration and intensity. moisture. hydration. lesions (distribution. Use the bell for low-pitched sounds like heart murmurs while the diaphragm screen for low-pitched and high-frequency sounds like breath sounds and pulses. deviations from midline. ulcerations and fissures. Percussion – Determine the density of the underlying tissues and whether it is air-filled. masses or foreign bodies. Review of Systems Neurologic – with the use of GLASGOW COMA SCALE. Tongue for its ability to protrude. Temperature – identify whether hypothermia. edema. bulbar and palpebral conjunctiva for congestion and color. strong. hygiene and grooming. Examine for the presence of discharges. configuration of skull. pallor. lesions. obstruction. Eyes and Vision – Inspect globes for protrusion. Ears and Hearing – Inspect for the size. arrangement and general condition of the teeth. swelling or tenderness of scalp and configuration of the skull. 2006) Inspection – Scrutinize the patient’s body and behavior. Obtain the height. restlessness. Check for the patency of the salivary glands. fasciculation. pigmentation. size). placement on the head. color. sensory function and deep tendon reflexes. affect. Palpate for edema and masses Head – Inspect for the symmetry of face. hair distribution and nails. Determine the strength of the upper lids by attempting to open closed lids against resistance. position and perforation. weight and BMI of the patient. ASSESSING FROM HEAD-TO-TOE (CEPHALO-CAUDAL) (Nettina. Uvula should be symmetry when . cerebellar function. BP within normal range and hypertension. pupils for size. normothermia and hyperthermia Pulse – assess if the pulse is full. 2. scalp. cyanosis. discharge. thickness. secretions. weber and rhine tests. Palpate pulses. impacted cerumen. jaundice. and position of lashes. texture. Palpation – Touch without or with pressure (as indicated) the region or body part to be observed and note for tenderness and what the various structures feel like. type. temperature. superficial vascularity. masses. Palpate for hair texture. texture. 2006) Assess vital signs 1. general physical development. Distinguish the different qualities of sound. exudates and masses. Integumentary – Inspect for skin color. shape. inflammation. Mouth – Inspect for the lips color. elasticity and turgor. hair color and distribution. Pharynx for inflammation. symmetry. Buccal mucosa should be observed for discoloration. reaction to light and accommodation —PERRLA (Pupil Equally Round and Reactive to Light Accomodation). bounding or thready. symmetry. nystagmus and convergence. apparent age. shape. configuration. eye movement for extraocular movements. erythema. clothes. Observe for gums color. ulcers and masses. pitch.Physical Assessment Techniques (Nettina. rubor and swelling. Inspect for the General Appearance . body position. and the visual acuity with the use of Snellen chart (with and without glasses). swelling or retraction. Blood pressure – measures hypotension. symmetry. motor function. Palpate sinuses for swelling and tenderness.Observe for race. Also. pubic hair distribution. discharge. Note for skin texture. scars. Percussion to identify heart border and area of cardiac dullness. masses. . shape. The intercostal spaces are referred to in terms of the rib immediately above the intercostal space. Palpate the muscles for size. bony overgrowth. Neck – Inspect for the symmetry and range of motion. Auscultate the breath sounds and identify the vesicular. dullness and tymphanism. Abdomen – Observe for the general contour of the abdomen. warmth. Palpate for tenderness. moisture and temperature. Palpate for masses. Auscultate for bowel sounds. Perform light palpation to detect any muscular resistance or guarding. pigmentation. bulges or retractions. masses and inflammation. The odor of the breath and the hoarseness of the voice should be examined. contour. the fifth intercostals space is directly below the fifth rib. The second rib joins the sternum at this prominent landmark. On the sides. Inspect the umbilicus for contour or hernia and the skin for rashes. Observe for the signs of pain and inflammation. Percuss the four abdominal quadrants noting its resonance. lesions and rashes or for any abnormal opening. Observe for the resonance. visible peristalsis and aortic pulsations. striae and scars. Check for size. perianal region and sacral region for inflammation. color. Genitalia – Inspect for the skin color and temperature. scars. sternal notch and angle of Louis to assess the right/left upper lung lobes. deformity and masses. or any abnormal curvature. tenderness or superficial organs or masses. structural deformity. Locating ribs on the posterior surface of the thorax is more difficult. tenderness. Elicit vocal and tactile fremitus by asking the patient to say “99”. midsternal line. heart and the heart sounds. inflammation and engorgement. Assess respiratory expansion. Deep palpation to assess location. for the size and shape irregularities. Auscultate to listen for bruits over the carotid arteries. for example. For male. bronchovesicular and bronchial or tubular. masses. Laurente et al. size and induration. symmetry. are posterior axillary line. swelling. consistency. note the character and frequency of bowel sounds including the pitch and duration. 2006. exudates and inflammation of the tonsils. This is accomplished by finding the seventh cervical vertebra (vertebra prominens). shape. 1997). LANDMARKS FOR PHYSICAL EXAMINATION Apices and bases of the lungs The structural landmarks of the chest are clavicle. strength. Percuss the chest and observe the percussion sounds for both sides. symmetry. nodules or masses. size. tone. ulcers. tenderness. shape. ulcerations. Lymph Nodes – Inspect and palpate for the size. heaving or thrusting and note for any other pulsations. crusting and masses. Bases of the lungs – the land marks are xiphoid process. pulsations and jugular vein distention. right/left anterior axillary line and the midclavicular line. nodules. thoracic locations are identified according to their proximity to the rib or the intercostal space under the examiner’s fingers. lateral curvature. Heart – Inspect the precordium for any bulging. Musculoskeletal – Inspect the upper and lower extremities for size. deformity and muscle mass. Apices of the lungs – the land marks are manubrium. Palpate for the tissue distribution. Other ribs may be identified by counting down from the second rib. pulsations and mobility of underlying organs and masses. Thorax and Lungs – Inspect for the ribs mobility. skin characteristics and level of breast. Palpate for lesions. Note gait and posture. Horizontally. On the anterior surface. enlargement and masses.. any contractures and tenderness. surface. inspect the nipple and areola for ulceration. Observe for retraction or dimpling of the skin. midaxillary line and anterior axillary line. consistency. Note any bulges after bearing down. Check the spine for range of motion. The first step is to identify the spinous process. tricuspid and mitral. Breasts – For female. Palpate for the vibrations and pulsations over aortic. inversion. Auscultate the aorta and renal arteries found at the upper quadrants and iliac arteries at the lower quadrants. Auscultate for the rhythm and rate of the pulses. swelling and discharges. contour. respiration and impairment of the respiratory movement. mobility. The anteroposterior (AP) diameter of the thorax in relation to the lateral diameter is approximately 1:2. nodules. Palpate the spine for bony deformities and crepitation. redness. Palpate for tenderness. shape. tenderness and inflammation. symmetry. tymphanism and dullness of percussion sounds. ulcerations. symmetry. swelling or discharge and tenderness. This is where the manubrium joins the body of the sternum in the midline. identification of a specific rib is facilitated by first locating the angle of Louis. pulmonic. Rectum – Inspect and palpate the anus.the patient says ―ah‖. inspect the areola and nipples for position. Check the size. Check the joints for range of motion. Palpate the inguinal area and anterior thigh. body of sternum and 4-7th ribs to assess the right/left lower lung lobes (Nettina. Tricuspid area is at the 5 th intercostal space next to the sternum. where it intersects the line between the upper and lower lobes and traverses horizontally to the sternum. Auscultating Bowel Sounds Bowel sounds can be heard like ―growling‖ sounds over the entire four quadrants of the abdomen (Nettina. the apical beat (the point of maximal impulse). and meets the sixth rib at the sternum. 2006). A line drawn vertically through the superior and inferior poles of the scapula is called the scapular line. CLINICAL IMPLICATIONS AND RELEVANCE OF PHYSICAL ASSESSMENT PARAMETERS . 2006). and a line drawn down the center of the vertebral column is called the vertebral line. Other vertebrae are then identified by counting downward (Smeltzer & Bare. the examiner communicates findings by referring to an area of dullness extending from the vertebral to the scapular line between the seventh and tenth ribs on the right (Smeltzer & Bare. 2004). S 2 results from the closing of the aortic and pulmonary valves. Vertical landmarks start at the midsternal line passes through the center of the sternum. Auscultating Normal Heart Sounds   First heart sound Second heart sound To visualize the position of the heart under the sternum and the ribs. All areas (4 quadrants) should be assessed to examine the entire colon and to determine the area of obstruction. There is no presentation of the middle lobe on the posterior surface of the chest (Smeltzer & Bare. S1 and S2 are of almost equal in intensity and in the mitral area. Using these landmarks. from the middle of the axilla. Apical impulse can be located on the 5-6th intercostals space or just medial to the midclavicular line. imaginary vertical lines may be drawn from the anterior axillary fold. Mitral area is the apex of the heart found at the 5 th intercostals space or just medial to the midclavicular line. Laurente et al. locate the intercostals spaces by identifying the angle of Louis felt as a slight ridge approximately 1 inch below the sternal notch where the manubrium and the body of the sternum are joined. the midaxillary line. In the tricuspid area. and the posterior axillary line. and from the posterior axillary fold. In the aortic and pulmonic areas. This line on the right divides the right middle lobe from the right lower lobe. The line dividing the right upper lobe from the middle lobe is an incomplete one that begins at the fifth rib in the midaxillary line. the seventh cervical spinous process stands out. The 2nd ribs extend to the right and left of this angle. 2004). The point of maximal impulse of the heart normally lies along this line on the left thorax. The right lower quadrant (RLQ) is the best site to auscultate bowel sounds for immediate examination (Hayes. S1 is caused by the closing of the tricuspid and mitral valves. the anterior axillary line. proceeds around to cross the fifth rib in the midaxillary line. S1 is often slightly louder than S2 (Nettina. When the neck is slightly flexed. Aortic area found at the 2 nd right intercostals space. These lines are called. The Erb’s point can be heard over the 3rd interspace close to the sternum. 1997). close to the sternum. Pulmonic area is at the 2nd left intercostals space. Area of Liver Palpation Palpate the liver by placing the left hand under the patient’s lower right rib cage and the right hand on the abdomen below the level of liver dullness (Nettina.which is the most prominent spinous process. respectively. S1 and S2 are heard as “lub” “dub”. Locate the 2nd rib. Thus. The midclavicular line is an imaginary line that descends from the middle of the clavicle. palpate downward and obliquely away from the sternum to identify the remaining ribs and intercostals spaces. Heart sounds can be auscultated over the pulmonic or aortic area. When the arm is abducted from the body at 90°. the upper lobes are dominant on the anterior surface of the thorax and the lower lobes are dominant on the posterior surface. S2 is usually louder than S1. The line between the upper and lower lobes on the left begins at the fourth thoracic spinous process posteriorly. for example.. 2004). 2007). 2006. temperature and sensations are indicators of peripheral oxygenation and venous / arterial blood flow. Vesicular breath sound has low pitch with soft intensity and located all over the lungs. LOC is a very significant indicator of oxygenation and tissue perfusion. is called Kussmaul’s respiration. It is also necessary to detect evidence of neurologic problem. If sustained. capilly refill. is created by an increase in pressure within the hemithorax. Apnea describes varying periods of cessation of breathing. This movement is normally symmetric. septicemia. metabolic acidosis. trauma). Hyperventilation that is marked by an increase in rate and depth. 2006). Asymmetric bulging of the intercostal spaces.Level of Consciousness Level of consciousness is gauged on a continuum with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. are cycles of breaths that vary in depth and have varying periods of apnea. pulmonary edema. Respiratory excursion is an estimation of thoracic expansion and may disclose significant information about thoracic movement during breathing. this will help to assess not only the blood volume of the body but the ability of the heart to pump blood and test the functions of the cardio-pulmonary and hematologic system (Smeltzer & Bare. and rib fracture. Tachypnea (rapid breathing) is commonly seen in patients with pneumonia. particularly if asymmetric. A disease will alter the normal bronchial. With rapid breathing. severe pain.. associated with severe acidosis of diabetic or renal origin. The level of consciousness can be an indication of the heart’s ability to propel oxygen to the brain (cerebral perfusion). Marked retraction on inspiration. It is quite normal to see a slight retraction of the intercostal spaces during quiet breathing of thin patient. Bradypnea (slow breathing) is associated with increased intracranial pressure. 2004). bleeding. Assymetrical Chest Expansion Chest movement should be symmetric and without lag or impairment (Nettina. brain injury and drug overdose. It is softer and much finer (vesicular) at the periphery over the alveoli. on one side or the other. Sounds may normally decrease in obese patients (Nettina. An increase in both rate and depth that a result in a lowered arterial PCO2 level is referred to as hyperventilation. 2004). Bronchial or tubular has high pitch and loud heard over the trachea. Breathing Patterns The rate and depth of respiration or the breathing pattern is a simple but important aspect of assessment. An increase in depth of respirations is called hyperpnea. Hypoventilation has shallow and irregular breathing. Biot’s respirations. Laurente et al. Cheyne-Stokes respiration is characterized by alternating episodes of apnea (cessation of breathing) and periods of deep breathing. Bronchovesicular has medium pitch with medium intensity heard near the main stem bronchi (below the clavicles and between the scapulae. or cluster breathing. 2004). Decreased chest . decreased circulating blood. The level of responsiveness and consciousness is the most important indicator of the patient’s condition (Smeltzer & Bare. 1997). This may be a result of air trapped under pressure within the pleural cavity where it does not normally appear (pneumothorax) or the pressure of fluid within the pleural space (pleural effusion). Also. Cheyne-Stokes respiration is usually associated with heart failure and damage to the respiratory center (drug-induced. Breath sounds vary according to proximity of the large bronchi. This helps to assess the peripheral system blood flow and its ability and capacity to maintain an adequately circulating blood volume for tissue oxygenation. This will also detect if the blood vessels are constricted or dilated. Peripheral Perfusion Assessing peripheral perfusion such as skin color. inspiration and expiration are nearly equal in duration. wheezes and ronchi. Adventitious sounds may indicate crackles. and fluid volume and cardiac output. tumor. infection (sepsis). 2006. Bulging during expiration implies obstruction of expiratory airflow as seen in emphysema. apnea is life-threatening. The normal breathing pattern is called eupnea. Breath sounds are louder and coarser near the large bronchi and over the anterior. especially on the right). implies blockage of a branch of the respiratory tree. Biot’s respirations are seen with some central nervous system disorders. bronchovesicular and ventricular breath sounds. Certain patterns of respiration are characteristic of specific disease states (Smeltzer & Bare. . Also. 2004). Prolonged corticosteroid therapy. Jugular vein distention is a sign of fluid and electrolyte imbalances and compromised regulatory mechanisms such as renal failure. congestion of the viscera and the peripheral tissues predominates. 2006). The increase in venous pressure leads to jugular vein distention (JVD).excursion may be due to chronic fibrotic disease. and hyperaldosteronism augment fluid volume excess (Smeltzer & Bare. Asymmetric excursion may be due to splinting secondary to pleurisy. it is associated with right-sided heart failure. This occurs because the right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation. heart failure. 2004). JVD is associated with fluid volume overload and pulmonary congestion or edema. fractured ribs. and cirrhosis and overzealous administration of sodium-containing fluids. severe stress. or unilateral bronchial obstruction (Smeltzer & Bare. trauma. Jugular Vein Distention Jugular vein distention can be an indication for a suspected compromise cardiac function (Nettina. When the right ventricle fails.