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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.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

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. 3rd stage of fever?
Pedal pulse
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.
Eupnea
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

2. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
tachycardia
Tachypnea
Diastolic pressure
Korotkoff sounds

3. Abnormal - nonmusical sound heard on ausculation of the lungs during inspiration; also called rales. Sound like hair rubbed between the fingers next to the ears.
3 in the right lung and 2 lobes in the left
crackles
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.
shallow or slow breathing

4. Healthly adult
12-20
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
pyrexia
Acute anxiety stimulate the nervous system - raising the pulse.

5. Average pulse rate for an adult
stridor
72 bpm
Crisis
Cheyenne-Stokes

6. Weak and regular (even beats wit poor force)
+1
Cardiac Output
popliteal
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

7. Taking axillary temperature
Stroke volume
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
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.

8. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
Acute anxiety stimulate the nervous system - raising the pulse.
stridor
from drug therapy - a neurologic problem or dehydration.
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.

9. How is pulse best found?
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.
hypoxemia
97.5 to 99.5
Korotkoff sounds Phase IV: Muffling

10. Louder knocking sound that occurs wit each heartbeat
Korotkoff sounds Phase III: Knocking
Conduction
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
the blood pressure will rise in order to push the blood along.

11. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Sinoatrial node (SA NODE)
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
60 to 70 mL
Evaporation

12. Stress & emotions. BP?
higher
Hyperthermia related to infection or excessive heat exposure
Cardiac Output
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

13. Drop in blood pressure when arising to a standing position.
Kussmaul's respiration
orthostatic hypertension
120/80
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

14. Taking a rectal temperature
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Brachial
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

15. How does disease increase the body's temperature?
about 1 degree higher than oral temperatures
the lungs
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

16. How is shock caused?
It will also fall
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
120/70
Korotkoff sounds Phase IV: Muffling

17. What are the 5 vital signs?
temperature - pulse - respiration - blood pressure - and pain level.
97.5 to 99.5
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
low BP

18. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
left Sims position
16-20
Cardiac Output
Respiration

19. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
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
higher
Nursing interventions to reduce fever

20. Does the respiration rate increase or decrease during fever?
Increases as body tries to remove excess heat
Posterior tibial
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Core Temperature

21. 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.
Cardiac Output
hypoxia
Apical
3 in the right lung and 2 lobes in the left

22. How does external respiration occur?
Biot's
absent
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
Korotkoff sounds Phase V: Silence

23. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
ausculatation
pyrogens
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
thready

24. What happens to the blood if overhydration occurs?
60 to 70 mL
20-30
Blood pressure increases because there is more volume of blood in the vascular system.
orthostatic hypertension

25. Increased rate and depth with panting and long grunting exhalation. Often seen with patients with acidosis and renal failure.

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26. Rectal temperature are
Dorsalis pedis
about 1 degree higher than oral temperatures
left Sims position
dehydration - delirium - and convulsons may occur. Dehydration will occur because of lost with perspiration and more rapid breathing. Delirium and convulsions may occur because neurologic function is affected when the temperature in the brain rises.

27. How should baby's temperature be taken?
Axillary.
tachycardia
carotid
Tall - slender people mayy ave a slower pulse rate than short - stout persons

28. The average temperature in the older adult
the blood pressure will rise in order to push the blood along.
hyperoxia
96.5 to 97.5
BMR

29. High oxygen
Pons and Medulla of the brainstem
hyperoxia
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
Evaporation

30. Head injury BP?
intermittent
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
raises BP.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

31. Elderly respiration
16-20
ausculatation
Pulse pressure
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

32. Abrupt decline in fever
Crisis
lysis
tachycardia
Temperature will remain below 102 degrees with use of hypothermia blanket

33. Gradual return to a normal temperature
higher
The pulse rate gradually diminishes from birth to adulthood
lysis
Irregular

34. 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
Blood pressure increases because there is more volume of blood in the vascular system.
Pons and Medulla of the brainstem
Nursing interventions to reduce fever
oximeter

35. What happens when vasodilation occurs?
Pulse pressure
hypoxia
Vascular resistance drops and the blood pressure decreases
120-139/80-89

36. What pulse is checked to determine whether there is any blockage of circulation in the artery up to that point - especially in patients who have had cardiac catherization using the femoral artery for the insertion of the catheter or those who had sur
Acute anxiety stimulate the nervous system - raising the pulse.
Diaphoresis
oximetry
Pedal pulse

37. Decreased levels of oxygen in the blood - often seen in patients wo are under medical sedation - who are recovering from anesthesia or abdominal surgery - or who are in a weak or debiliated condition.
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
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.
hypoxemia
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

38. What should you do if you cannot determine BP by ausculation?
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
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.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
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.

39. A normal - relaxed breathing pattern
about 1 degree higher than oral temperatures
intermittent
Febrile stage - the body temperature rises to a new set point established by the hypothalamus and remains there until there is a resolution to the cause of fever.
Eupnea

40. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
low
arrhythmia
hyperoxia
Apical

41. How does menstrual cycle and pregnancy raise the body's temperature?
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
blood pressure is lowest in the morning. and higher in the afternoone
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
+1

42. 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
Hyperventilation
Systolic pressure
Kussmaul's respiration
Stroke volume

43. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Korotkoff sounds Phase IV: Muffling
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Pulse
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

44. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
120-139/80-89
It increases to push the blood through more rigid pathways.
Hypothermia
Korotkoff sounds

45. When should rectal temperatures be used?
lysis
intermittent
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
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

46. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Hypothermia
Tall - slender people mayy ave a slower pulse rate than short - stout persons

47. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
ausculatation
Korotkoff sounds
the blood pressure will rise in order to push the blood along.

48. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
16-20
men - African Americans - under a lot of stress - obese
low BP
Evaporation

49. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Cheyenne-Stokes
Febrile stage - the body temperature rises to a new set point established by the hypothalamus and remains there until there is a resolution to the cause of fever.
Crisis
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

50. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
raises BP.
Sinoatrial node (SA NODE)
remittent
constant