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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. Newborn
hyperoxia
low
30-80
Korotkoff sounds Phase IV: Muffling

2. How does increased body temperature increase the pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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.
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.

3. What are the 5 vital signs?
hypoxia
20-30
Temporal
temperature - pulse - respiration - blood pressure - and pain level.

4. Taking axillary temperature
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
hypoxia
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 will also fall

5. 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?
palpate
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Nursing interventions to reduce fever

6. Disappearance of sound. (marks diastolic pressure in adults)
Rhonchi
Brachial
Sinoatrial node (SA NODE)
Korotkoff sounds Phase V: Silence

7. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Korotkoff sounds Phase IV: Muffling
Stroke volume
remittent
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

8. 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.
in the alveoli - tiny thin-walled sacs
crackles
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
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.

9. 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.
Blood pressure increases because there is more volume of blood in the vascular system.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
remittent

10. The rate at which heat is produced when the body is at rest.
It increases to push the blood through more rigid pathways.
BMR
Convection
Diastolic pressure

11. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
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.
Temperature will remain below 102 degrees with use of hypothermia blanket
the blood pressure will rise in order to push the blood along.
cardiac patients or patients who have had rectal surgery.

12. What should you do if you cannot determine BP by ausculation?
low
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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.
Acute anxiety stimulate the nervous system - raising the pulse.

13. When should rectal temperatures NOT be used?
Pedal pulse
cardiac patients or patients who have had rectal surgery.
Hyperthermia related to infection or excessive heat exposure
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

14. BP at or lower 90/60.
Hyperthermia related to infection or excessive heat exposure
men - African Americans - under a lot of stress - obese
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
hypotension

15. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
constant
Pons and Medulla of the brainstem
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Increases as body tries to remove excess heat

16. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
stridor
wheeze
120/70
Sinoatrial node (SA NODE)

17. 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
Temporal
Pedal pulse
Tachypnea
120-139/80-89

18. How does physical exercise raise the body's temperature?
absent
about 1 degree lower than oral temperatures
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.
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.

19. Gas exchange in the blood occurs where?
It will also fall
in the alveoli - tiny thin-walled sacs
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Tachypnea

20. The volume of blood pushed into the aorta per heartbeat.
apnea
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Stroke volume

21. No pulse palpable or heard on ausculation
30-80
the blood pressure will rise in order to push the blood along.
remittent
absent

22. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
16-20
palpate
constant
Pulse

23. How do drugs affect pulse?
shallow or slow breathing
It increases to push the blood through more rigid pathways.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

24. Stress & emotions. BP?
higher
Pulse
Temperature will remain below 102 degrees with use of hypothermia blanket
pyrogens

25. Low oxygen
hypoxia
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Conduction
Femoral

26. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
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.
Conduction
It increases to push the blood through more rigid pathways.
hypertension

27. What happens to the blood if overhydration occurs?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Korotkoff sounds Phase V: Silence
Blood pressure increases because there is more volume of blood in the vascular system.
Brachial

28. Rectal temperature are
hyperoxia
Biot's
popliteal
about 1 degree higher than oral temperatures

29. 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
hypoxia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Nursing interventions to reduce fever
Diastolic pressure

30. Adolescent
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.
16-20
pyrexia
^160/^100

31. Diurnal variation BP?
blood pressure is lowest in the morning. and higher in the afternoone
intermittent
cardiac patients or patients who have had rectal surgery.
lysis

32. When should rectal temperatures be used?
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
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.
absent
Korotkoff sounds Phase III: Knocking

33. High BP
hypertension
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Evaporation
absent

34. Korotkoff sounds Ausculatatory gap:
Pedal pulse
Stroke volume
Korotkoff sounds Phase II Swishing
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

35. Side of neck
+1
Stertor
Core Temperature
carotid

36. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
stridor
low BP
Brachial
Korotkoff sounds Phase IV: Muffling

37. Measurement of oxygen
oximetry
120/80
hypertension
Blood pressure increases because there is more volume of blood in the vascular system.

38. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
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
20-30

39. What affects does aging do to the respiratory rate?
+2
left Sims position
Temporal
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

40. Heart
It increases to push the blood through more rigid pathways.
Apical
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Rhonchi

41. Air movemtn causes heat to be transferred from the skin to the air molecules.
hypoxia
Apical
Korotkoff sounds Phase II Swishing
Convection

42. Fast - deep respirations with abrupt pauses

43. Obtaining the correct size for a cuff for BP?
12-20
Biot's respirations
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
intermittent

44. 3 yr old
orthostatic hypertension
low
Korotkoff sounds Phase III: Knocking
20-30

45. 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.
97.5 to 99.5
remittent
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
carotid

46. Are infants blood pressure low or high?
Cheyenne-Stokes
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.
low
about 1 degree lower than oral temperatures

47. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
arrhythmia
Korotkoff sounds
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.
thready

48. How do you measure the apical pulse?
men - African Americans - under a lot of stress - obese
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
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
from drug therapy - a neurologic problem or dehydration.

49. Whats the best position to take a rectal temperature?
Irregular
Core Temperature
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
left Sims position

50. What characteristics should be noted when checking the pulse?
Respiration
uncooperative patient - children - combative patients - dementia
the rate - the rhythm - and volume
Posterior tibial