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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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1. Fever above 100.2 F
thready
hypoxemia
The emotions increase hormone secretion - and the body activities required for this increase heat production.
pyrexia

2. How is pulse best found?
Biot's respirations
Eupnea
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.

3. Pulse above 100 beats per 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.
arrhythmia
Cheyenne-Stokes
tachycardia

4. When should rectal temperatures NOT be used?
Axillary.
cardiac patients or patients who have had rectal surgery.
Radial
shallow or slow breathing

5. How does disease increase the body's temperature?
oximetry
uncooperative patient - children - combative patients - dementia
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Blood pressure increases because there is more volume of blood in the vascular system.

6. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Irregular
Evaporation
The pulse rate gradually diminishes from birth to adulthood
Blood pressure increases because there is more volume of blood in the vascular system.

7. Rectal temperature are
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
apnea
about 1 degree higher than oral temperatures
lysis

8. Air movemtn causes heat to be transferred from the skin to the air molecules.
Convection
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
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.
crackles

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

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10. How should respirations be counted?
dyspnea
Respiration
Sinoatrial node (SA NODE)
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

11. What are the 5 vital signs?
+3
temperature - pulse - respiration - blood pressure - and pain level.
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

12. A pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled - causing te blood level of carbon dioxide to fall. this condition is seen after sever exertion - during high levels of anxiety o
Diaphoresis
Hyperventilation
Stroke Volume
intermittent

13. When the heart contracts How many mLs of blood is propelled into the aorta?
pyrexia
60 to 70 mL
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
+3

14. The pulse rate multiplied by the stroke volume. This is the amount of blood pumped by the left ventricle in 1 minute. Averaging at about 5mL per minute.
Nursing interventions to reduce fever
hypertension
Temperature will remain below 102 degrees with use of hypothermia blanket
Cardiac Output

15. How do you measure the apical pulse?
Radial
in the alveoli - tiny thin-walled sacs
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
fever

16. What affects does aging do to the blood pressure?
hypoxia
96.5 to 97.5
uncooperative patient - children - combative patients - dementia
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

17. Side of wrist
Blood pressure increases because there is more volume of blood in the vascular system.
Biot's respirations
Radial
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.

18. The maximum pressure exerted on the artery during left ventricular contraction.
Systolic pressure
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
intermittent
temperature - pulse - respiration - blood pressure - and pain level.

19. Adolescent
16-20
Biot's
hypoxia
higher

20. Are infants blood pressure low or high?
+3
apnea
oximetry
low

21. 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.
remittent
the lungs
bradycardia
Hypothermia

22. The average temperature in the older adult
140-159/90-99
96.5 to 97.5
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.
Vascular resistance drops and the blood pressure decreases

23. When should rectal temperatures be used?
96.5 to 97.5
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
12-20
Tall - slender people mayy ave a slower pulse rate than short - stout persons

24. How do emotions increase the pulse rate?
absent
It increases to push the blood through more rigid pathways.
Acute anxiety stimulate the nervous system - raising the pulse.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

25. Average pulse rate for an adult
72 bpm
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
popliteal
120/70

26. Stage 1 hypertension
140-159/90-99
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.
Hypothermia
about 1 degree lower than oral temperatures

27. Absence of breathing
raises BP.
Acute anxiety stimulate the nervous system - raising the pulse.
ausculatation
apnea

28. 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
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.
Femoral
Pedal pulse
thready

29. BP at or lower 90/60.
16-20
ausculatation
hypotension
Irregular

30. Full and bounding (even beats wit strong force)
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.
60 to 70 mL
+3
absent

31. 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?
constant
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Cheyenne-Stokes
96.5 to 97.5

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

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33. Elevated temperature
fever
Convection
oximeter
Irregular

34. Barely palpable
Feeble
uncooperative patient - children - combative patients - dementia
Kussmaul's respiration
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

35. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
It increases to push the blood through more rigid pathways.
bradypnea
Hypothermia
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

36. Pulse lower than 60 beats per minute
oximetry
Cheyenne-Stokes
pyrexia
bradycardia

37. Gas exchange in the blood occurs where?
+1
in the alveoli - tiny thin-walled sacs
Core Temperature
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.

38. State of insufficient oxygen
hypoxia
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 III: Knocking
apnea

39. Heart
uncooperative patient - children - combative patients - dementia
Eupnea
Apical
constant

40. Enviromental temperature BP?
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.
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.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
about 1 degree lower than oral temperatures

41. Korotkoff sounds Ausculatatory gap:
Increases as body tries to remove excess heat
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.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
crackles

42. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Cardiac Output
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
Pons and Medulla of the brainstem
Conduction

43. Blood pressure for any adult should be no higher than
120/80
Dorsalis pedis
72 bpm
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

44. Obtaining the correct size for a cuff for BP?
Acute anxiety stimulate the nervous system - raising the pulse.
hypoxia
blood pressure is lowest in the morning. and higher in the afternoone
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

45. How does physical exercise raise the body's temperature?
Korotkoff sounds Phase II Swishing
Stertor
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.

46. How do drugs affect pulse?
hypoxemia
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
palpate

47. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
It will also fall
Rhonchi
left Sims position
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

48. High oxygen
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.
tachycardia
hyperoxia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

49. 2nd stage of fever is?
higher
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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.
wheeze

50. Elderly respiration
from drug therapy - a neurologic problem or dehydration.
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
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.
16-20

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Measuring Vital Signs

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