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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. Those at risk for hypothermia include
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.
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.
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.

2. Korotkoff sounds Ausculatatory gap:
Pons and Medulla of the brainstem
Convection
Stroke Volume
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

3. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
the rate - the rhythm - and volume
Korotkoff sounds Phase IV: Muffling
Respiration
Core Temperature

4. Side of forehead
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.
Stertor
3 in the right lung and 2 lobes in the left
Temporal

5. Pulse above 100 beats per minute
tachycardia
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Sinoatrial node (SA NODE)
arrhythmia

6. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
the lungs
Evaporation
Radial

7. Are infants blood pressure low or high?
the blood pressure will rise in order to push the blood along.
low
Pulse
systolic pressure indicated by faint - clear sound that gradually grow louder.

8. Risk for prolonged hypertension
Evaporation
palpate
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Core Temperature

9. How does menstrual cycle and pregnancy raise the body's temperature?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Korotkoff sounds Phase V: Silence
stridor
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

10. How does the time of day (circadian rhythm) affect the body's temperature?

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11. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Korotkoff sounds
hypoxemia
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
arrhythmia

12. No pulse palpable or heard on ausculation
from drug therapy - a neurologic problem or dehydration.
120/80
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.
absent

13. Average pulse rate for an adult
absent
72 bpm
The emotions increase hormone secretion - and the body activities required for this increase heat production.
+2

14. right arm vs. left arm/ arm vs. leg BP?
BMR
carotid
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

15. What affects does aging do to the heart rate?

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16. Elderly respiration
temperature - pulse - respiration - blood pressure - and pain level.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Vascular resistance drops and the blood pressure decreases
16-20

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

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18. What should you do if you cannot determine BP by ausculation?
Apical
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.
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.
remittent

19. 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
Apical
oximetry
hypoxia

20. When is apicial pulse used?
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
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 pulse rate increases at the rate of 7-10 beats for each degree of temperature
Pons and Medulla of the brainstem

21. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
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.
The pulse rate gradually diminishes from birth to adulthood
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
arrhythmia

22. Taking axillary temperature
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Relapsing
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.
dyspnea

23. Gas exchange in the blood occurs where?
in the alveoli - tiny thin-walled sacs
higher
16-20
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

24. Bend of elbow
hypoxemia
pyrexia
Brachial
hyperoxia

25. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
Rhonchi
+3
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

26. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
bradypnea
Rhonchi
12-20
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

27. How does external respiration occur?
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
Cardiac Output
30-80
Pedal pulse

28. How should respirations be counted?
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
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
remittent
wheeze

29. Barely palpable
Tachypnea
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.
Feeble
Cardiac Output

30. 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
12-20
3 in the right lung and 2 lobes in the left
Nursing interventions to reduce fever
140-159/90-99

31. Low oxygen
+2
raises BP.
hypoxia
It increases to push the blood through more rigid pathways.

32. Absence of breathing
Hyperthermia related to infection or excessive heat exposure
apnea
blood pressure is lowest in the morning. and higher in the afternoone
Eupnea

33. Average blood pressure should be
Acute anxiety stimulate the nervous system - raising the pulse.
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.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
120/70

34. Slow and shallow breathing - leads to hypoxemia.
72 bpm
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Korotkoff sounds Phase V: Silence
bradypnea

35. When the heart contracts How many mLs of blood is propelled into the aorta?
60 to 70 mL
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
about 1 degree lower than oral temperatures
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

36. Diurnal variation BP?
120-139/80-89
blood pressure is lowest in the morning. and higher in the afternoone
hypoxemia
hyperoxia

37. How does physical exercise raise the body's temperature?
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
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.
arrhythmia
the lungs

38. State of insufficient oxygen
hypoxia
Sinoatrial node (SA NODE)
about 1 degree higher than oral temperatures
hypotension

39. 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.
remittent
oximeter
Crisis
97.5 to 99.5

40. What characteristics should be noted when checking the pulse?
the rate - the rhythm - and volume
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
120/70
Acute anxiety stimulate the nervous system - raising the pulse.

41. How do emotions increase the pulse rate?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Acute anxiety stimulate the nervous system - raising the pulse.
oximeter
from drug therapy - a neurologic problem or dehydration.

42. Rectal temperature are
Biot's respirations
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.
about 1 degree higher than oral temperatures
left Sims position

43. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
popliteal
the blood pressure will rise in order to push the blood along.
It increases to push the blood through more rigid pathways.
Femoral

44. The temperature falls to normal and then rises again in a repeating pattern.
Nursing interventions to reduce fever
Korotkoff sounds Phase II Swishing
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Relapsing

45. 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.
apnea
crackles
Biot's respirations
Blood pressure increases because there is more volume of blood in the vascular system.

46. The difference between the systolic pressure and the diastolic pressure
Irregular
Pulse pressure
+1
blood pressure is lowest in the morning. and higher in the afternoone

47. An example of nursing planning
Stroke volume
16-20
pyrexia
Temperature will remain below 102 degrees with use of hypothermia blanket

48. Full and bounding (even beats wit strong force)
pyrexia
Core Temperature
Pulse
+3

49. Why would patients experience orthostatic hypotenstion?
low
120/70
from drug therapy - a neurologic problem or dehydration.
higher

50. Side of neck
the rate - the rhythm - and volume
Pons and Medulla of the brainstem
Stroke volume
carotid