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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. How does physical exercise raise the body's temperature?
It uses large muscles in the body - which create body heat by burning up the glucose and fat in the tissues - muscle action generates heat and core temperature rises.
about 1 degree higher than oral temperatures
Nursing interventions to reduce fever
dyspnea

2. Signs and symptoms of shock
120/80
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Relapsing
the blood pressure will rise in order to push the blood along.

3. Pulse lower than 60 beats per minute
Eupnea
bradycardia
palpate
Relapsing

4. Encourage a large fluid intake - lower room temperature - increase air circulation - remove items of clothes - control or reduce the amount of body activity - carry out physicians orders
Vascular resistance drops and the blood pressure decreases
Nursing interventions to reduce fever
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Pons and Medulla of the brainstem

5. Difference between the apical and radial pulse - this requires two people to count the radial and apicial pulses at the same time to determine whether there is a what?
Hyperventilation
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
low
low BP

6. Weak and regular (even beats wit poor force)
The body's temperature in the morning is usually low from inactivity of the muscles. The afternooon body temperature may be high-normal because of the body's metabolic processes - the patient's activity - and the temperature of the environment.
+1
palpate
Feeble

7. High oxygen
the blood pressure will rise in order to push the blood along.
hyperoxia
Cardiac Output
bradypnea

8. Head injury BP?
+3
bradypnea
Axillary.
raises BP.

9. BP at or lower 90/60.
hypotension
+1
Biot's
hypoxia

10. Side of neck
carotid
Nursing interventions to reduce fever
Dorsalis pedis
uncooperative patient - children - combative patients - dementia

11. When is apicial pulse used?
when it is difficult to find or to count the radial pulse - or for patients with heart conditions for one full minute by placing stethoscope on the heart to count for a full minute.
cardiac patients or patients who have had rectal surgery.
Temporal
low BP

12. What affects does aging do to the respiratory rate?
temperature - pulse - respiration - blood pressure - and pain level.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Respiration
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

13. Both strong and weak beats occur within 1 minute
determine if the patient has a known heart arrhythmia - perform hand hygiene - expose the left chest - warm the stethoscope in hand for a min or 2 - locate the apex of the heart by palpating for the 5th intercostal space at the midclavicular line. li
pyrogens
Cheyenne-Stokes
Irregular

14. Does the respiration rate increase or decrease during fever?
^160/^100
Biot's respirations
Increases as body tries to remove excess heat
Korotkoff sounds Phase II Swishing

15. How does emotional stress raise the body's temperature?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Korotkoff sounds Phase II Swishing
crackles
Acute anxiety stimulate the nervous system - raising the pulse.

16. Taking axillary temperature
place the thermometer in the center of the patients dry axilla. Ask patient to hold the arm tightly against the chest. Leave in place 3-8 minutes.
by placing the flat part of the first fingers against the tendon - or cord - on the thumb inside of the inner wrist and ten rolling the fingers slightly outward into the little trough on the thumb inside the wrist.
the rate - the rhythm - and volume
hypoxia

17. Top of left foot
Cheyenne-Stokes
popliteal
Dorsalis pedis
It will also fall

18. A high temperature falls - usually in the morning - and again rises later in the day. The temperature never fails to normal in this type of fever until recovery occurs.
cardiac patients or patients who have had rectal surgery.
remittent
1) ventilation - Which is the movement of air in and out of the lung. 2) dispersion of air throughout the bronchial tree of the lungs; 3) diffusion of oxygen and carbon dioxide molecules across the alveolar membranes; 4) perfusion - the movement of b
It increases to push the blood through more rigid pathways.

19. The average temperature in the older adult
Hyperventilation
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
carotid
96.5 to 97.5

20. Why would patients experience orthostatic hypotenstion?
systolic pressure indicated by faint - clear sound that gradually grow louder.
Temporal
apnea
from drug therapy - a neurologic problem or dehydration.

21. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
oximeter
palpate
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
It uses large muscles in the body - which create body heat by burning up the glucose and fat in the tissues - muscle action generates heat and core temperature rises.

22. Measurement of oxygen
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
oximetry
constant
60 to 70 mL

23. A pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled - causing te blood level of carbon dioxide to fall. this condition is seen after sever exertion - during high levels of anxiety o
It uses large muscles in the body - which create body heat by burning up the glucose and fat in the tissues - muscle action generates heat and core temperature rises.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Hyperventilation

24. What should you do if you cannot determine BP by ausculation?
intermittent
the palpation method is used. put cuff over arm - feel the radial point to get the systolic pressure you cant get the diastolic this way.
Eupnea
When an accurate temperature cant be obtained orally and a tympanic or temporal artery thermometer are not available. It may be used when there is nasal congestion or there has been nasal or oral surgery - the patient is unable to keep their mouth cl

25. Increased or rapid breathing results from te presence of fever and a number or diseases. breathing rate increased about 4 breaths for each degree increase in temperature.
the palpation method is used. put cuff over arm - feel the radial point to get the systolic pressure you cant get the diastolic this way.
Tachypnea
Onset - which may occur gradually or suddenly. the body responds to a pyrogen by trying to conserve and manufacture heat to raise the set point for core temperature. The person will feel cold - and will add clothes or covers - curl up in a ball - and
blood pressure is lowest in the morning. and higher in the afternoone

26. Feel
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
low
palpate

27. What characteristics should be noted when checking the pulse?
Brachial
Acute anxiety stimulate the nervous system - raising the pulse.
ausculatation
the rate - the rhythm - and volume

28. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
wheeze
oximeter
dyspnea
Tachypnea

29. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
1) ventilation - Which is the movement of air in and out of the lung. 2) dispersion of air throughout the bronchial tree of the lungs; 3) diffusion of oxygen and carbon dioxide molecules across the alveolar membranes; 4) perfusion - the movement of b
ausculatation
Korotkoff sounds Phase III: Knocking
Cheyenne-Stokes

30. The pulse rate multiplied by the stroke volume. This is the amount of blood pumped by the left ventricle in 1 minute. Averaging at about 5mL per minute.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
3 in the right lung and 2 lobes in the left
Cardiac Output
hypotension

31. How does age affect pulse?
The pulse rate gradually diminishes from birth to adulthood
fever
1) ventilation - Which is the movement of air in and out of the lung. 2) dispersion of air throughout the bronchial tree of the lungs; 3) diffusion of oxygen and carbon dioxide molecules across the alveolar membranes; 4) perfusion - the movement of b
place the thermometer in the center of the patients dry axilla. Ask patient to hold the arm tightly against the chest. Leave in place 3-8 minutes.

32. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
Systolic pressure
bradypnea
Diastolic pressure
pyrogens

33. Shallow for two or three breaths with a period of variable apnea. occur in patients with increased intracranial pressure.

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34. Average blood pressure should be
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
by placing the flat part of the first fingers against the tendon - or cord - on the thumb inside of the inner wrist and ten rolling the fingers slightly outward into the little trough on the thumb inside the wrist.
120/70
It will also fall

35. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
tachycardia
by placing the flat part of the first fingers against the tendon - or cord - on the thumb inside of the inner wrist and ten rolling the fingers slightly outward into the little trough on the thumb inside the wrist.
1) ventilation - Which is the movement of air in and out of the lung. 2) dispersion of air throughout the bronchial tree of the lungs; 3) diffusion of oxygen and carbon dioxide molecules across the alveolar membranes; 4) perfusion - the movement of b
Stertor

36. Excessive sweat production
Blood pressure increases because there is more volume of blood in the vascular system.
absent
Diaphoresis
Respiration

37. No pulse palpable or heard on ausculation
Diaphoresis
absent
left Sims position
Tall - slender people mayy ave a slower pulse rate than short - stout persons

38. Gradual return to a normal temperature
Cardiac Output
oximetry
Korotkoff sounds Phase III: Knocking
lysis

39. By measuring the blood pressure you obtain vital info about what?
the effectiveness of the heart contractions - the amount of blood in the system - and the presence of any obstruction or interference of blood to the blood vessels
pyrogens
the blood pressure will rise in order to push the blood along.
hypertension

40. Risk for prolonged hypertension
by placing the flat part of the first fingers against the tendon - or cord - on the thumb inside of the inner wrist and ten rolling the fingers slightly outward into the little trough on the thumb inside the wrist.
Core Temperature
140-159/90-99
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

41. How does size affect pulse?
Acute anxiety stimulate the nervous system - raising the pulse.
blood pressure is lowest in the morning. and higher in the afternoone
Korotkoff sounds Phase III: Knocking
Tall - slender people mayy ave a slower pulse rate than short - stout persons

42. Blood pressure for any adult should be no higher than
120/80
Cheyenne-Stokes
higher
postoperative patients wo have been cooled during surgery - newborn infants whose skin is exposed to cool room temperatures - elderly or debiliated patients - and those exposed to cold temperatures for prolonged periods.

43. How is shock caused?
determine if the patient has a known heart arrhythmia - perform hand hygiene - expose the left chest - warm the stethoscope in hand for a min or 2 - locate the apex of the heart by palpating for the 5th intercostal space at the midclavicular line. li
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Vascular resistance drops and the blood pressure decreases
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

44. When the heart contracts How many mLs of blood is propelled into the aorta?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
60 to 70 mL
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Sinoatrial node (SA NODE)

45. Murmur or swishing sounds that increase as the cuff is deflated
Biot's respirations
Korotkoff sounds Phase II Swishing
when it is difficult to find or to count the radial pulse - or for patients with heart conditions for one full minute by placing stethoscope on the heart to count for a full minute.
the rate - the rhythm - and volume

46. Whats the best position to take a rectal temperature?
in the alveoli - tiny thin-walled sacs
Stroke Volume
left Sims position
Evaporation

47. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
It increases to push the blood through more rigid pathways.
hypertension
30-80
hypotension

48. Weak and may be irregular
Cardiac Output
males have higher bp - until menopause then they are the same
thready
the rate - the rhythm - and volume

49. How is pulse best found?
arrhythmia
the palpation method is used. put cuff over arm - feel the radial point to get the systolic pressure you cant get the diastolic this way.
when it is difficult to find or to count the radial pulse - or for patients with heart conditions for one full minute by placing stethoscope on the heart to count for a full minute.
by placing the flat part of the first fingers against the tendon - or cord - on the thumb inside of the inner wrist and ten rolling the fingers slightly outward into the little trough on the thumb inside the wrist.

50. Fever above 100.2 F
oximetry
pyrexia
ausculatation
Hyperthermia related to infection or excessive heat exposure