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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. What characteristics should be noted when checking the pulse?
Diaphoresis
low
the rate - the rhythm - and volume
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.

2. Side of forehead
men - African Americans - under a lot of stress - obese
Temporal
Hyperventilation
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

3. How is shock caused?
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.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
blood pressure is lowest in the morning. and higher in the afternoone

4. Fast - deep respirations with abrupt pauses

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5. Bend of elbow
Blood pressure increases because there is more volume of blood in the vascular system.
Brachial
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
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

6. Healthly adult
orthostatic hypertension
120/80
12-20
It increases to push the blood through more rigid pathways.

7. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Stertor
Dorsalis pedis
Evaporation
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

8. 1st stage of fever is?
pyrogens
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Diaphoresis
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

9. When should rectal temperatures NOT be used?
Korotkoff sounds
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
72 bpm
cardiac patients or patients who have had rectal surgery.

10. Groin area
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
Femoral
crackles

11. Drop in blood pressure when arising to a standing position.
Korotkoff sounds Phase II Swishing
orthostatic hypertension
Dorsalis pedis
Acute anxiety stimulate the nervous system - raising the pulse.

12. Alternating rise and fall of the temperature.
apnea
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.
dyspnea
intermittent

13. Gradual return to a normal temperature
Cheyenne-Stokes
lysis
BMR
shallow or slow breathing

14. Korotkoff sounds Phase I: Tapping
hypoxemia
absent
systolic pressure indicated by faint - clear sound that gradually grow louder.
Acute anxiety stimulate the nervous system - raising the pulse.

15. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Eupnea
uncooperative patient - children - combative patients - dementia
Cheyenne-Stokes
Pons and Medulla of the brainstem

16. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
arrhythmia
carotid
16-20
shallow or slow breathing

17. How does menstrual cycle and pregnancy raise the body's temperature?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Respiration
Conduction
Nursing interventions to reduce fever

18. No pulse palpable or heard on ausculation
Femoral
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.
hyperoxia
absent

19. Feel
palpate
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
120-139/80-89
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

20. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
Feeble
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
low BP
Increases as body tries to remove excess heat

21. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
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.
low BP
constant
Relapsing

22. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
Biot's
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
crackles
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

23. The difference between the systolic pressure and the diastolic pressure
Korotkoff sounds
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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
Pulse pressure

24. Rectal temperature are
Sinoatrial node (SA NODE)
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.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
about 1 degree higher than oral temperatures

25. 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
crackles
Korotkoff sounds Phase V: Silence
Vascular resistance drops and the blood pressure decreases

26. 3 yr old
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
lysis
20-30
Conduction

27. Diurnal variation BP?
Convection
absent
blood pressure is lowest in the morning. and higher in the afternoone
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

28. Slow and shallow breathing - leads to hypoxemia.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
bradypnea
pyrogens
Diaphoresis

29. 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
oximeter
Pedal pulse
Brachial
remittent

30. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
men - African Americans - under a lot of stress - obese
dyspnea
constant
the lungs

31. Stress & emotions. BP?
fever
Stroke Volume
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
higher

32. Average blood pressure should be
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
120/70
Rhonchi
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

33. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
16-20
Cardiac Output
120/80

34. Absence of breathing
^160/^100
apnea
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
shallow or slow breathing

35. How is pulse best found?
males have higher bp - until menopause then they are the same
+2
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
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.

36. Measurement of oxygen
bradypnea
140-159/90-99
intermittent
oximetry

37. High BP
hypertension
Respiration
cardiac patients or patients who have had rectal surgery.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

38. Full and bounding (even beats wit strong force)
about 1 degree lower than oral temperatures
oximetry
Diaphoresis
+3

39. How does emotional stress raise the body's temperature?
Pulse pressure
The emotions increase hormone secretion - and the body activities required for this increase heat production.
It will also fall
tachycardia

40. Side of wrist
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Pulse pressure
Radial
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

41. 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
The emotions increase hormone secretion - and the body activities required for this increase heat production.
palpate
Nursing interventions to reduce fever
Stroke Volume

42. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
remittent
Rhonchi
Biot's respirations
12-20

43. 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?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Acute anxiety stimulate the nervous system - raising the pulse.
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.
140-159/90-99

44. The rate at which heat is produced when the body is at rest.
BMR
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
Feeble
60 to 70 mL

45. Abrupt decline in fever
Crisis
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
constant
uncooperative patient - children - combative patients - dementia

46. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
Biot's respirations
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
30-80
It increases to push the blood through more rigid pathways.

47. Obtaining the correct size for a cuff for BP?
Systolic pressure
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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
tachycardia

48. Murmur or swishing sounds that increase as the cuff is deflated
hypoxia
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
the lungs
Korotkoff sounds Phase II Swishing

49. What should you do if you cannot determine BP by ausculation?
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.
Korotkoff sounds Phase IV: Muffling
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.
apnea

50. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Hyperventilation
Diastolic pressure