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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
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. 3 yr old
ausculatation
hypoxia
Eupnea
20-30

2. Stage 1 hypertension
low BP
Cheyenne-Stokes
Evaporation
140-159/90-99

3. An example of nursing planning
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
+3
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Temperature will remain below 102 degrees with use of hypothermia blanket

4. Gas exchange in the blood occurs where?
+1
in the alveoli - tiny thin-walled sacs
dyspnea
left Sims position

5. 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.
Cardiac Output
from drug therapy - a neurologic problem or dehydration.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
crackles

6. Disappearance of sound. (marks diastolic pressure in adults)
Diastolic pressure
Korotkoff sounds Phase V: Silence
about 1 degree higher than oral temperatures
140-159/90-99

7. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
dyspnea
pyrexia

8. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Stertor
Korotkoff sounds
temperature - pulse - respiration - blood pressure - and pain level.
Hypothermia

9. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Stroke Volume
Respiration
males have higher bp - until menopause then they are the same
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

10. Newborn
Hyperthermia related to infection or excessive heat exposure
the blood pressure will rise in order to push the blood along.
Korotkoff sounds Phase IV: Muffling
30-80

11. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
oximeter
hypoxia
Biot's

12. Abrupt decline in fever
constant
Convection
Crisis
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

13. Feel
Brachial
Hyperventilation
blood pressure is lowest in the morning. and higher in the afternoone
palpate

14. How does external respiration occur?
^160/^100
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 II Swishing
remittent

15. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
low
dyspnea
Temporal

16. 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
lysis
temperature - pulse - respiration - blood pressure - and pain level.
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.

17. How does menstrual cycle and pregnancy raise the body's temperature?
higher
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
about 1 degree lower than oral temperatures
Korotkoff sounds

18. Top of left foot
Korotkoff sounds Phase III: Knocking
Dorsalis pedis
cardiac patients or patients who have had rectal surgery.
low BP

19. 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
Pedal pulse
crackles
20-30
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

20. 3rd stage of fever?
left Sims position
orthostatic hypertension
ausculatation
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

21. The rate at which heat is produced when the body is at rest.
60 to 70 mL
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
97.5 to 99.5
BMR

22. Both strong and weak beats occur within 1 minute
140-159/90-99
Stroke Volume
Irregular
120/70

23. Those at risk for hypothermia include
Evaporation
arrhythmia
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 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

24. Fever above 100.2 F
pyrexia
+3
Korotkoff sounds Phase II Swishing
Irregular

25. Louder knocking sound that occurs wit each heartbeat
Vascular resistance drops and the blood pressure decreases
BMR
oximeter
Korotkoff sounds Phase III: Knocking

26. How should respirations be counted?
60 to 70 mL
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
^160/^100
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

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

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28. Rectal temperature are
about 1 degree higher than oral temperatures
crackles
Dorsalis pedis
Increases as body tries to remove excess heat

29. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
about 1 degree higher than oral temperatures
+3
It will also fall

30. What affects does aging do to the blood pressure?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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.
constant
hypertension

31. The average temperature in the older adult
low BP
96.5 to 97.5
thready
hypertension

32. Korotkoff sounds Ausculatatory gap:
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Nursing interventions to reduce fever
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.
Dorsalis pedis

33. Fast - deep respirations with abrupt pauses

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34. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
Eupnea
Pons and Medulla of the brainstem
ausculatation
arrhythmia

35. Lobes in the lungs?
about 1 degree higher than oral temperatures
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Sinoatrial node (SA NODE)
3 in the right lung and 2 lobes in the left

36. Stress & emotions. BP?
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
higher
men - African Americans - under a lot of stress - obese
Increases as body tries to remove excess heat

37. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Stroke volume
Kussmaul's respiration
dyspnea

38. 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.
Tachypnea
pyrogens
Pulse pressure
Biot's

39. Head injury BP?
raises BP.
Acute anxiety stimulate the nervous system - raising the pulse.
140-159/90-99
120-139/80-89

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

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41. The volume of blood pushed into the aorta per heartbeat.
Stroke volume
120-139/80-89
Core Temperature
140-159/90-99

42. BP at or lower 90/60.
hypotension
blood pressure is lowest in the morning. and higher in the afternoone
30-80
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

43. Diurnal variation BP?
+3
ausculatation
blood pressure is lowest in the morning. and higher in the afternoone
Evaporation

44. Elevated temperature
orthostatic hypertension
fever
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Hypothermia

45. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Evaporation
Sinoatrial node (SA NODE)
pyrexia
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

46. What happens when vasodilation occurs?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Vascular resistance drops and the blood pressure decreases
Conduction

47. 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.
Crisis
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
hypoxemia
systolic pressure indicated by faint - clear sound that gradually grow louder.

48. A normal - relaxed breathing pattern
Eupnea
Feeble
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

49. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
higher
16-20
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.
Diastolic pressure

50. 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
72 bpm
thready
hypertension