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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. Blood pressure for any adult should be no higher than
120/80
pyrexia
30-80
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.

2. What affects does aging do to the heart rate?

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3. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
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.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
crackles
Pulse pressure

4. Pulse lower than 60 beats per minute
bradypnea
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Blood pressure increases because there is more volume of blood in the vascular system.
bradycardia

5. 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
Kussmaul's respiration
raises BP.
cardiac patients or patients who have had rectal surgery.

6. Murmur or swishing sounds that increase as the cuff is deflated
Korotkoff sounds Phase II Swishing
Biot's
120/70
Dorsalis pedis

7. Absence of breathing
shallow or slow breathing
thready
apnea
Blood pressure increases because there is more volume of blood in the vascular system.

8. Are infants blood pressure low or high?
low
Hyperthermia related to infection or excessive heat exposure
about 1 degree higher than oral temperatures
Nursing interventions to reduce fever

9. By measuring the blood pressure you obtain vital info about what?
from drug therapy - a neurologic problem or dehydration.
Biot's respirations
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
pyrexia

10. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Rhonchi
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
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.
palpate

11. Top of left foot
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.
Brachial
Dorsalis pedis
Feeble

12. Average blood pressure should be
Diaphoresis
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
hypoxia
120/70

13. Fast - deep respirations with abrupt pauses

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14. Gradual return to a normal temperature
temperature - pulse - respiration - blood pressure - and pain level.
lysis
97.5 to 99.5
Blood pressure increases because there is more volume of blood in the vascular system.

15. When should rectal temperatures NOT be used?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
cardiac patients or patients who have had rectal surgery.
Korotkoff sounds Phase V: Silence

16. Axillary temperature are
Pedal pulse
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.
about 1 degree lower than oral temperatures
Relapsing

17. The difference between the systolic pressure and the diastolic pressure
Pulse pressure
BMR
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Pons and Medulla of the brainstem

18. 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
20-30
constant
popliteal

19. 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
popliteal
Systolic pressure
bradypnea

20. right arm vs. left arm/ arm vs. leg BP?
Stroke volume
men - African Americans - under a lot of stress - obese
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Pedal pulse

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

22. Feel
+1
tachycardia
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
palpate

23. Groin area
oximeter
low
Femoral
from drug therapy - a neurologic problem or dehydration.

24. What happens when vasodilation occurs?
absent
Vascular resistance drops and the blood pressure decreases
Pedal pulse
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

25. What happens to the blood if overhydration occurs?
16-20
72 bpm
pyrexia
Blood pressure increases because there is more volume of blood in the vascular system.

26. 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.
palpate
hypoxemia
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
Biot's respirations

27. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
shallow or slow breathing
Nursing interventions to reduce fever
Vascular resistance drops and the blood pressure decreases
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

28. Disappearance of sound. (marks diastolic pressure in adults)
120-139/80-89
stridor
Korotkoff sounds Phase V: Silence
Vascular resistance drops and the blood pressure decreases

29. Weak and may be irregular
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
dyspnea
thready

30. 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.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
The pulse rate gradually diminishes from birth to adulthood
Diaphoresis
crackles

31. Bend of knee
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
lysis
popliteal
Core Temperature

32. An example of nursing planning
Temperature will remain below 102 degrees with use of hypothermia blanket
Irregular
^160/^100
Diaphoresis

33. How does external respiration occur?
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
Biot's respirations
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
Vascular resistance drops and the blood pressure decreases

34. High BP
palpate
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
hypertension
orthostatic hypertension

35. Korotkoff sounds Ausculatatory gap:
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
Acute anxiety stimulate the nervous system - raising the pulse.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

36. 2nd stage of fever is?
Brachial
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.
It increases to push the blood through more rigid pathways.
shallow or slow breathing

37. Strong and regular ( even beats wit moderate force)
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
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.
120/80
+2

38. Substances tat cause fever
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.
Diaphoresis
about 1 degree higher than oral temperatures
pyrogens

39. If the cardiac output falls what will happen to the BP?
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.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
120/80

40. 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.
Korotkoff sounds Phase II Swishing
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
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

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

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42. Healthly adult
12-20
blood pressure is lowest in the morning. and higher in the afternoone
Hyperthermia related to infection or excessive heat exposure
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

43. 3rd stage of fever?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

44. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Systolic pressure
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.
Evaporation

45. The average temperature in the older adult
intermittent
+2
Radial
96.5 to 97.5

46. What patients should not use a glass thermometer orally?
uncooperative patient - children - combative patients - dementia
60 to 70 mL
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 BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

47. How do drugs affect pulse?
^160/^100
Convection
+2
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

48. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
72 bpm
stridor
about 1 degree lower than oral temperatures
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.

49. Excessive sweat production
hypoxia
apnea
Diaphoresis
Temporal

50. Abrupt decline in fever
Posterior tibial
Feeble
Crisis
Temperature will remain below 102 degrees with use of hypothermia blanket