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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. Korotkoff sounds Phase I: Tapping
hypertension
bradycardia
Sinoatrial node (SA NODE)
systolic pressure indicated by faint - clear sound that gradually grow louder.

2. Obtaining the correct size for a cuff for BP?
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Korotkoff sounds Phase III: Knocking
120/80

3. Rectal temperature are
+1
about 1 degree higher than oral temperatures
3 in the right lung and 2 lobes in the left
cardiac patients or patients who have had rectal surgery.

4. Murmur or swishing sounds that increase as the cuff is deflated
arrhythmia
Nursing interventions to reduce fever
BMR
Korotkoff sounds Phase II Swishing

5. High BP
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
hypertension
bradypnea
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

6. Symptoms of hypoxia
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
140-159/90-99
oximeter

7. 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
temperature - pulse - respiration - blood pressure - and pain level.
Nursing interventions to reduce fever
Conduction
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

8. Absence of breathing
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.
apnea
Nursing interventions to reduce fever
Hypothermia

9. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Temporal
Cheyenne-Stokes
Conduction
the rate - the rhythm - and volume

10. Prehypertension
120-139/80-89
absent
72 bpm
Korotkoff sounds

11. Bend of knee
Tachypnea
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
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.
popliteal

12. How is pulse best found?
Stroke Volume
Evaporation
cardiac patients or patients who have had rectal surgery.
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. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
stridor
Respiration
Hypothermia
20-30

14. How should respirations be counted?
Nursing interventions to reduce fever
72 bpm
16-20
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

15. Healthly adult
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.
Cheyenne-Stokes
12-20
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.

16. Gradual return to a normal temperature
Stroke Volume
Vascular resistance drops and the blood pressure decreases
lysis
The emotions increase hormone secretion - and the body activities required for this increase heat production.

17. Heart
low BP
Apical
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
absent

18. Elevated temperature
fever
Hyperthermia related to infection or excessive heat exposure
low BP
thready

19. right arm vs. left arm/ arm vs. leg BP?
hypoxia
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
bradypnea
Core Temperature

20. Side of neck
carotid
It increases to push the blood through more rigid pathways.
Biot's
bradycardia

21. What happens to the blood if overhydration occurs?
in the alveoli - tiny thin-walled sacs
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.
16-20
Blood pressure increases because there is more volume of blood in the vascular system.

22. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
low BP
Pulse pressure
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.
Crisis

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

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24. Pulse lower than 60 beats per minute
bradycardia
Korotkoff sounds
stridor
bradypnea

25. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
Temporal
It increases to push the blood through more rigid pathways.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
60 to 70 mL

26. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
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.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Evaporation
Apical

27. Bend of elbow
Sinoatrial node (SA NODE)
Systolic pressure
Brachial
Hyperventilation

28. High oxygen
hyperoxia
Stroke Volume
ausculatation
Femoral

29. How should baby's temperature be taken?
pyrexia
males have higher bp - until menopause then they are the same
Axillary.
hypoxemia

30. Axillary temperature are
Korotkoff sounds
Hyperthermia related to infection or excessive heat exposure
about 1 degree lower than oral temperatures
Convection

31. When the heart contracts How many mLs of blood is propelled into the aorta?
Feeble
BMR
60 to 70 mL
carotid

32. The average temperature in the older adult
120/70
It will also fall
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.
96.5 to 97.5

33. Elderly respiration
Korotkoff sounds
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
Vascular resistance drops and the blood pressure decreases
16-20

34. 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
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
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.
hypoxia

35. Alternating rise and fall of the 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.
intermittent
16-20
hypotension

36. The temperature falls to normal and then rises again in a repeating pattern.
Relapsing
16-20
intermittent
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

37. Korotkoff sounds Ausculatatory gap:
Femoral
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Evaporation

38. The volume of blood pushed into the aorta per heartbeat.
remittent
left Sims position
hypoxia
Stroke volume

39. 3 yr old
20-30
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
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.
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

40. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Stertor
pyrogens
30-80
Core Temperature

41. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
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.
pyrogens
Tall - slender people mayy ave a slower pulse rate than short - stout persons

42. Those at risk for hypothermia include
Feeble
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.
Stroke Volume
Conduction

43. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
+3
Diastolic pressure
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

44. Low oxygen
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
Femoral
fever
hypoxia

45. Taking a rectal temperature
It increases to push the blood through more rigid pathways.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Stroke volume
systolic pressure indicated by faint - clear sound that gradually grow louder.

46. When warm skin touches a cool object - heat is lost to the object.
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.
Brachial
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
Conduction

47. Risk for prolonged hypertension
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
12-20
higher
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

48. How does emotional stress raise the body's temperature?
Apical
The emotions increase hormone secretion - and the body activities required for this increase heat production.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
hypoxia

49. 3rd stage of fever?
Stroke volume
Eupnea
The pulse rate gradually diminishes from birth to adulthood
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

50. Whats the best position to take a rectal temperature?
Cardiac Output
left Sims position
72 bpm
Acute anxiety stimulate the nervous system - raising the pulse.