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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 are the 5 vital signs?
temperature - pulse - respiration - blood pressure - and pain level.
the rate - the rhythm - and volume
hypertension
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

2. 3 yr old
20-30
120-139/80-89
Korotkoff sounds Phase II Swishing
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

3. When should rectal temperatures NOT be used?
96.5 to 97.5
BMR
120/70
cardiac patients or patients who have had rectal surgery.

4. How is shock caused?
lysis
Eupnea
Pulse
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

5. How does physical exercise raise the body's 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.
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.
Korotkoff sounds Phase V: Silence
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.

6. Lobes in the lungs?
It increases to push the blood through more rigid pathways.
Core Temperature
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.
3 in the right lung and 2 lobes in the left

7. Groin area
72 bpm
Femoral
men - African Americans - under a lot of stress - obese
20-30

8. Healthly adult
the rate - the rhythm - and volume
left Sims position
12-20
hypotension

9. Signs and symptoms of shock
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Hyperventilation
shallow or slow breathing
pyrexia

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

11. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
absent
Tachypnea
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.
popliteal

12. High BP
hypertension
60 to 70 mL
Biot's
intermittent

13. How is pulse best found?
popliteal
pyrogens
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.
blood pressure is lowest in the morning. and higher in the afternoone

14. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
Relapsing
Femoral
constant
Pulse

15. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
ausculatation
Temperature will remain below 102 degrees with use of hypothermia blanket
shallow or slow breathing
Acute anxiety stimulate the nervous system - raising the pulse.

16. Taking axillary temperature
12-20
Kussmaul's respiration
+3
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.

17. By measuring the blood pressure you obtain vital info about what?
Nursing interventions to reduce fever
bradypnea
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
+2

18. How do drugs affect pulse?
Korotkoff sounds Phase II Swishing
fever
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Hypothermia

19. Average blood pressure should be
about 1 degree higher than oral temperatures
Stroke Volume
dyspnea
120/70

20. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
pyrogens
dyspnea
Hyperthermia related to infection or excessive heat exposure
Stertor

21. How do emotions increase the pulse rate?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
16-20
Acute anxiety stimulate the nervous system - raising the pulse.
Temperature will remain below 102 degrees with use of hypothermia blanket

22. Air movemtn causes heat to be transferred from the skin to the air molecules.
Convection
Cardiac Output
from drug therapy - a neurologic problem or dehydration.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

23. Those at risk for hypothermia include
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.
3 in the right lung and 2 lobes in the left
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
low

24. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
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
temperature - pulse - respiration - blood pressure - and pain level.
stridor
Korotkoff sounds Phase III: Knocking

25. Substances tat cause fever
Cardiac Output
Blood pressure increases because there is more volume of blood in the vascular system.
Hyperventilation
pyrogens

26. Are infants blood pressure low or high?
low BP
low
hypertension
lysis

27. Feel
Systolic pressure
+2
palpate
Pulse pressure

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.
Apical
12-20
thready

29. Bend of knee
ausculatation
pyrexia
120-139/80-89
popliteal

30. Full and bounding (even beats wit strong force)
+3
The pulse rate gradually diminishes from birth to adulthood
Sinoatrial node (SA NODE)
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

31. 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
Posterior tibial
males have higher bp - until menopause then they are the same
Axillary.
Pedal pulse

32. Why would patients experience orthostatic hypotenstion?
+2
from drug therapy - a neurologic problem or dehydration.
Dorsalis pedis
120/70

33. Drop in blood pressure when arising to a standing position.
BMR
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
orthostatic hypertension

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

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35. Korotkoff sounds Phase I: Tapping
systolic pressure indicated by faint - clear sound that gradually grow louder.
Nursing interventions to reduce fever
fever
Posterior tibial

36. Louder knocking sound that occurs wit each heartbeat
Korotkoff sounds Phase III: Knocking
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
uncooperative patient - children - combative patients - dementia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

37. Side of neck
Radial
hypoxia
97.5 to 99.5
carotid

38. 1st stage of fever is?
Systolic pressure
low BP
140-159/90-99
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

39. Adolescent
Respiration
Cardiac Output
Systolic pressure
16-20

40. People most at risk for hypertension
Crisis
low BP
thready
men - African Americans - under a lot of stress - obese

41. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
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
tachycardia
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
dyspnea

42. How does emotional stress raise the body's temperature?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
cardiac patients or patients who have had rectal surgery.
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.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

43. 3rd stage of fever?
apnea
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.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
3 in the right lung and 2 lobes in the left

44. How does increased body temperature increase the pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Crisis
30-80
Radial

45. Gas exchange in the blood occurs where?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
in the alveoli - tiny thin-walled sacs
Sinoatrial node (SA NODE)
dyspnea

46. What characteristics should be noted when checking 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.
the rate - the rhythm - and volume
hypotension
Systolic pressure

47. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Sinoatrial node (SA NODE)
Temperature will remain below 102 degrees with use of hypothermia blanket
Respiration
It will also fall

48. Subnormal body temperature the regulating center in the hypothalamus is greatly impaired when the temperature of the body falls below 94 degrees - at that point? sleepiness and coma are apt to develop.
hypoxia
Stroke Volume
Hypothermia
Pons and Medulla of the brainstem

49. 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.
shallow or slow breathing
pyrogens
bradypnea
hypoxemia

50. Side of wrist
males have higher bp - until menopause then they are the same
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.
Temporal
Radial