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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. The average temperature in the older adult
Rhonchi
Tachypnea
hypoxia
96.5 to 97.5

2. Fast - deep respirations with abrupt pauses

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3. When is apicial pulse used?
12-20
Blood pressure increases because there is more volume of blood in 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.
Korotkoff sounds Phase V: Silence

4. 2nd stage of fever is?
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.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
intermittent
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

5. 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.
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.
hyperoxia
hypoxemia
16-20

6. A normal - relaxed breathing pattern
dyspnea
Eupnea
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
blood pressure is lowest in the morning. and higher in the afternoone

7. What are the 5 vital signs?
temperature - pulse - respiration - blood pressure - and pain level.
Korotkoff sounds Phase II Swishing
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Evaporation

8. High BP
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
tachycardia
hypertension
Sinoatrial node (SA NODE)

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
higher
Nursing interventions to reduce fever
Korotkoff sounds Phase V: Silence
lysis

10. Average pulse rate for an adult
72 bpm
The pulse rate gradually diminishes from birth to adulthood
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Temporal

11. Taking a rectal temperature
16-20
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
raises BP.
tachycardia

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

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13. Stage 2 hypertension
Pulse
^160/^100
about 1 degree lower than oral temperatures
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

14. Stress & emotions. BP?
low BP
hypoxia
^160/^100
higher

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

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16. Symptoms of hypoxia
It increases to push the blood through more rigid pathways.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Hypothermia
hypoxia

17. How should respirations be counted?
16-20
It increases to push the blood through more rigid pathways.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
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.

18. What happens to the blood if overhydration occurs?
left Sims position
Sinoatrial node (SA NODE)
absent
Blood pressure increases because there is more volume of blood in the vascular system.

19. What happens when vasodilation occurs?
Vascular resistance drops and the blood pressure decreases
crackles
60 to 70 mL
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

20. How does size affect pulse?
the blood pressure will rise in order to push the blood along.
lysis
Tall - slender people mayy ave a slower pulse rate than short - stout persons
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

21. Alternating rise and fall of the temperature.
intermittent
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.
hypoxemia
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

22. 1st stage of fever is?
Vascular resistance drops and the blood pressure decreases
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 will also fall
constant

23. Top of left foot
Dorsalis pedis
Blood pressure increases because there is more volume of blood in the vascular system.
intermittent
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

24. 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
constant
apnea
16-20

25. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Pons and Medulla of the brainstem
Dorsalis pedis
from drug therapy - a neurologic problem or dehydration.
Axillary.

26. High oxygen
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
hypoxia
hyperoxia
Radial

27. Diurnal variation BP?
140-159/90-99
Blood pressure increases because there is more volume of blood in the vascular system.
blood pressure is lowest in the morning. and higher in the afternoone
males have higher bp - until menopause then they are the same

28. Abrupt decline in fever
low
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Crisis
low BP

29. Whats the best position to take a rectal temperature?
Radial
hypertension
left Sims position
uncooperative patient - children - combative patients - dementia

30. Those at risk for hypothermia include
lysis
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
Pedal pulse

31. Groin area
hypoxia
Femoral
hypoxia
Dorsalis pedis

32. Average blood pressure should be
120/70
Vascular resistance drops and the blood pressure decreases
Axillary.
Stertor

33. Weak and may be irregular
thready
Hyperventilation
the rate - the rhythm - and volume
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.

34. Gas exchange in the blood occurs where?
Kussmaul's respiration
3 in the right lung and 2 lobes in the left
cardiac patients or patients who have had rectal surgery.
in the alveoli - tiny thin-walled sacs

35. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
It increases to push the blood through more rigid pathways.
the lungs
+1
Increases as body tries to remove excess heat

36. Korotkoff sounds Ausculatatory gap:
Crisis
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Acute anxiety stimulate the nervous system - raising the pulse.

37. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Hyperthermia related to infection or excessive heat exposure
wheeze
from drug therapy - a neurologic problem or dehydration.
Femoral

38. How does disease increase the body's temperature?
16-20
Hypothermia
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
absent

39. What should you do if you cannot determine BP by ausculation?
hyperoxia
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.
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.
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

40. 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.
bradypnea
20-30
stridor

41. Enviromental temperature BP?
Vascular resistance drops and the blood pressure decreases
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 lungs
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

42. Murmur or swishing sounds that increase as the cuff is deflated
Korotkoff sounds Phase III: Knocking
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Eupnea
Korotkoff sounds Phase II Swishing

43. 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.
Core Temperature
remittent
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.
120/70

44. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
It increases to push the blood through more rigid pathways.
Respiration
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

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.
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.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Korotkoff sounds
crackles

46. Korotkoff sounds Phase I: Tapping
systolic pressure indicated by faint - clear sound that gradually grow louder.
Radial
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.
Stertor

47. Weak and regular (even beats wit poor force)
Diastolic pressure
Crisis
absent
+1

48. What affects does aging do to the blood pressure?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Nursing interventions to reduce fever
shallow or slow breathing
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

49. Signs and symptoms of shock
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Irregular
It will also fall
BMR

50. How does external respiration occur?
Cheyenne-Stokes
arrhythmia
wheeze
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