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

2. Slow and shallow breathing - leads to hypoxemia.
bradypnea
Tachypnea
the rate - the rhythm - and volume
wheeze

3. How does physical exercise raise the body's 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.
in the alveoli - tiny thin-walled sacs
Stroke volume
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.

4. When warm skin touches a cool object - heat is lost to the object.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
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.
Korotkoff sounds Phase II Swishing
Conduction

5. How should respirations be counted?
Radial
Posterior tibial
pyrogens
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

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

7. What are the 5 vital signs?
temperature - pulse - respiration - blood pressure - and pain level.
97.5 to 99.5
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Rhonchi

8. How does menstrual cycle and pregnancy raise the body's temperature?
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.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Brachial
the lungs

9. 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
Conduction
temperature - pulse - respiration - blood pressure - and pain level.
Relapsing
Nursing interventions to reduce fever

10. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
hyperoxia
temperature - pulse - respiration - blood pressure - and pain level.
low BP
Core Temperature

11. 3 yr old
Acute anxiety stimulate the nervous system - raising the pulse.
crackles
20-30
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

12. 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.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
low
crackles
pyrogens

13. Side of forehead
intermittent
12-20
60 to 70 mL
Temporal

14. Fever above 100.2 F
30-80
apnea
pyrexia
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

15. Elevated temperature
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
fever
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

16. Excessive sweat production
Diaphoresis
raises BP.
hypoxia
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

17. When the heart contracts How many mLs of blood is propelled into the aorta?
60 to 70 mL
oximeter
Korotkoff sounds
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

18. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
raises BP.
Diastolic pressure
crackles

19. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Feeble
low
systolic pressure indicated by faint - clear sound that gradually grow louder.
Korotkoff sounds Phase IV: Muffling

20. Louder knocking sound that occurs wit each heartbeat
Femoral
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
dyspnea
Korotkoff sounds Phase III: Knocking

21. What affects does aging do to the respiratory rate?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
left Sims position

22. Bend of elbow
Relapsing
Brachial
absent
stridor

23. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
stridor
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.
palpate
Tachypnea

24. How is shock caused?
orthostatic hypertension
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Acute anxiety stimulate the nervous system - raising the pulse.
Korotkoff sounds Phase III: Knocking

25. Blood pressure for any adult should be no higher than
120/80
men - African Americans - under a lot of stress - obese
12-20
Tall - slender people mayy ave a slower pulse rate than short - stout persons

26. How does emotional stress raise the body's temperature?
low BP
16-20
stridor
The emotions increase hormone secretion - and the body activities required for this increase heat production.

27. Air movemtn causes heat to be transferred from the skin to the air molecules.
ausculatation
hypoxia
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Convection

28. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
Nursing interventions to reduce fever
Kussmaul's respiration
arrhythmia
Conduction

29. Barely palpable
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Cheyenne-Stokes
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.
Feeble

30. Normal body temperature ranges?
3 in the right lung and 2 lobes in the left
Blood pressure increases because there is more volume of blood in the vascular system.
shallow or slow breathing
97.5 to 99.5

31. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
97.5 to 99.5
systolic pressure indicated by faint - clear sound that gradually grow louder.
Rhonchi
low

32. How is pulse best found?
It will also fall
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.
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.
12-20

33. Stage 1 hypertension
140-159/90-99
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
120/70

34. Gradual return to a normal temperature
lysis
fever
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

35. 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
hyperoxia
^160/^100
Hyperthermia related to infection or excessive heat exposure

36. The difference between the systolic pressure and the diastolic pressure
Pulse pressure
Korotkoff sounds Phase V: Silence
Femoral
16-20

37. Disappearance of sound. (marks diastolic pressure in adults)
Increases as body tries to remove excess heat
men - African Americans - under a lot of stress - obese
+2
Korotkoff sounds Phase V: Silence

38. Stage 2 hypertension
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.
Hyperthermia related to infection or excessive heat exposure
20-30
^160/^100

39. Bend of knee
Cheyenne-Stokes
uncooperative patient - children - combative patients - dementia
popliteal
stridor

40. Symptoms of hypoxia
low BP
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
Brachial

41. Strong and regular ( even beats wit moderate force)
+2
oximetry
30-80
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

42. Weak and may be irregular
BMR
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.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
thready

43. Are infants blood pressure low or high?
bradypnea
low
shallow or slow breathing
Nursing interventions to reduce fever

44. Substances tat cause fever
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
pyrogens
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

45. Lobes in the lungs?
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.
3 in the right lung and 2 lobes in the left
Korotkoff sounds
97.5 to 99.5

46. Does the respiration rate increase or decrease during fever?
Increases as body tries to remove excess heat
Diastolic pressure
Tachypnea
96.5 to 97.5

47. Enviromental temperature BP?
bradypnea
wheeze
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
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.

48. How do you measure the apical pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of 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
temperature - pulse - respiration - blood pressure - and pain level.
Kussmaul's respiration

49. An example of a nursing diagnoses
pyrexia
Hyperthermia related to infection or excessive heat exposure
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
120/70

50. How does increased body temperature increase the pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Systolic pressure
Temperature will remain below 102 degrees with use of hypothermia blanket
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

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Measuring Vital Signs

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