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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. Healthly adult
12-20
Blood pressure increases because there is more volume of blood in the vascular system.
bradycardia
Cheyenne-Stokes

2. Axillary temperature are
Tall - slender people mayy ave a slower pulse rate than short - stout persons
arrhythmia
16-20
about 1 degree lower than oral temperatures

3. 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
Hyperventilation
Blood pressure increases because there is more volume of blood in the vascular system.
Diastolic pressure
120/80

4. By measuring the blood pressure you obtain vital info about what?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Korotkoff sounds Phase II Swishing
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
left Sims position

5. Low oxygen
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
30-80
hypoxia
Evaporation

6. 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.
Cardiac Output
Rhonchi
16-20
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

7. Obtaining the correct size for a cuff for BP?
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
carotid
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

8. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
shallow or slow breathing
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.
Biot's
Posterior tibial

9. Signs and symptoms of shock
Evaporation
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
16-20
Stroke volume

10. How is pulse best found?
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.
Stroke volume
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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

11. Average pulse rate for an adult
uncooperative patient - children - combative patients - dementia
Pedal pulse
+2
72 bpm

12. An example of a nursing diagnoses
Core Temperature
Hyperthermia related to infection or excessive heat exposure
60 to 70 mL
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.

13. Rectal temperature are
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
lysis
about 1 degree higher than oral temperatures

14. 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.
pyrogens
hypoxemia
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.
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

15. How does size affect pulse?
about 1 degree lower than oral temperatures
Tall - slender people mayy ave a slower pulse rate than short - stout persons
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Core Temperature

16. When should rectal temperatures NOT be used?
20-30
cardiac patients or patients who have had rectal surgery.
Blood pressure increases because there is more volume of blood in the vascular system.
Relapsing

17. Absence of breathing
tachycardia
apnea
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.
Core Temperature

18. 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
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.
The pulse rate gradually diminishes from birth to adulthood
Convection

19. If the cardiac output falls what will happen to the BP?
Evaporation
shallow or slow breathing
Biot's respirations
It will also fall

20. Average blood pressure should be
120/80
hypotension
Hyperthermia related to infection or excessive heat exposure
120/70

21. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
higher
16-20
Korotkoff sounds Phase IV: Muffling
males have higher bp - until menopause then they are the same

22. Korotkoff sounds Ausculatatory gap:
lysis
arrhythmia
hypoxemia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

23. right arm vs. left arm/ arm vs. leg BP?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Hyperthermia related to infection or excessive heat exposure
Diaphoresis
Korotkoff sounds Phase II Swishing

24. What patients should not use a glass thermometer orally?
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.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
20-30
uncooperative patient - children - combative patients - dementia

25. 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.
Stroke Volume
remittent
ausculatation
Sinoatrial node (SA NODE)

26. An example of nursing planning
97.5 to 99.5
Temperature will remain below 102 degrees with use of hypothermia blanket
Feeble
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

27. Slow and shallow breathing - leads to hypoxemia.
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.
Nursing interventions to reduce fever
raises BP.
bradypnea

28. Abrupt decline in fever
60 to 70 mL
Hyperthermia related to infection or excessive heat exposure
Crisis
Pulse pressure

29. Diurnal variation BP?
blood pressure is lowest in the morning. and higher in the afternoone
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.
hypoxia
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.

30. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Korotkoff sounds
hypoxia
shallow or slow breathing
about 1 degree higher than oral temperatures

31. Gas exchange in the blood occurs where?
in the alveoli - tiny thin-walled sacs
Pons and Medulla of the brainstem
Eupnea
Cheyenne-Stokes

32. How does physical exercise raise the body's temperature?
low BP
uncooperative patient - children - combative patients - dementia
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.
Stroke Volume

33. How should baby's temperature be taken?
Hypothermia
carotid
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Axillary.

34. Elevated temperature
fever
arrhythmia
97.5 to 99.5
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. Korotkoff sounds Phase I: Tapping
shallow or slow breathing
Temporal
pyrexia
systolic pressure indicated by faint - clear sound that gradually grow louder.

36. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
systolic pressure indicated by faint - clear sound that gradually grow louder.
It increases to push the blood through more rigid pathways.
stridor
Femoral

37. How does menstrual cycle and pregnancy raise the body's temperature?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Biot's respirations
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
+1

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.
stridor
Crisis
Tachypnea
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

39. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
30-80
It increases to push the blood through more rigid pathways.
Pulse

40. What characteristics should be noted when checking the pulse?
tachycardia
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.
arrhythmia
the rate - the rhythm - and volume

41. Weak and regular (even beats wit poor force)
Rhonchi
+1
Temporal
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.

42. Pulse lower than 60 beats per minute
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.
ausculatation
bradycardia
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.

43. Side of wrist
Hyperthermia related to infection or excessive heat exposure
Radial
lysis
oximeter

44. How does age affect pulse?
the lungs
Hyperventilation
The pulse rate gradually diminishes from birth to adulthood
120/70

45. Fever above 100.2 F
pyrexia
Systolic pressure
oximetry
The emotions increase hormone secretion - and the body activities required for this increase heat production.

46. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
higher
Stertor
Korotkoff sounds

47. Prehypertension
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.
Acute anxiety stimulate the nervous system - raising the pulse.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
120-139/80-89

48. How is shock caused?
Korotkoff sounds Phase III: Knocking
orthostatic hypertension
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
oximeter

49. Stage 1 hypertension
140-159/90-99
97.5 to 99.5
remittent
Korotkoff sounds Phase V: Silence

50. Newborn
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
60 to 70 mL
97.5 to 99.5
30-80