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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. High BP
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
hypertension
tachycardia
Cardiac Output

2. Barely palpable
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.
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.
+1
Feeble

3. Elevated temperature
remittent
fever
20-30
low

4. Symptoms of hypoxia
Apical
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Respiration

5. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Sinoatrial node (SA NODE)
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Hypothermia
Relapsing

6. 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
the blood pressure will rise in order to push the blood along.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
It increases to push the blood through more rigid pathways.
Hyperventilation

7. How does size affect pulse?
wheeze
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
dyspnea

8. Bend of elbow
It increases to push the blood through more rigid pathways.
hyperoxia
Brachial
bradypnea

9. When should rectal temperatures NOT be used?
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
cardiac patients or patients who have had rectal surgery.
about 1 degree higher than oral temperatures
Nursing interventions to reduce fever

10. 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?
thready
Pulse pressure
shallow or slow breathing
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

11. 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
+3
Brachial
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

12. Gradual return to a normal temperature
lysis
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
stridor
popliteal

13. 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
Pulse
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.
hypertension
Nursing interventions to reduce fever

14. Normal body temperature ranges?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
97.5 to 99.5
^160/^100
Convection

15. How should respirations be counted?
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Korotkoff sounds Phase II Swishing
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Dorsalis pedis

16. How does menstrual cycle and pregnancy raise the body's temperature?
Temporal
wheeze
Rhonchi
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

17. Average pulse rate for an adult
72 bpm
pyrexia
Systolic pressure
crackles

18. Pulse lower than 60 beats per minute
bradycardia
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
60 to 70 mL

19. People most at risk for hypertension
Pons and Medulla of the brainstem
men - African Americans - under a lot of stress - obese
blood pressure is lowest in the morning. and higher in the afternoone
dyspnea

20. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Korotkoff sounds Phase II Swishing
Pons and Medulla of the brainstem
Eupnea
hypotension

21. 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
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
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
16-20

22. Obtaining the correct size for a cuff for BP?
carotid
raises BP.
Pedal pulse
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

23. How do you measure the apical pulse?
left Sims position
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
16-20
Korotkoff sounds Phase III: Knocking

24. Pulse above 100 beats per minute
tachycardia
Pons and Medulla of the brainstem
Tachypnea
oximeter

25. Stage 2 hypertension
Cardiac Output
Posterior tibial
^160/^100
Apical

26. The maximum pressure exerted on the artery during left ventricular contraction.
Core Temperature
systolic pressure indicated by faint - clear sound that gradually grow louder.
Temperature will remain below 102 degrees with use of hypothermia blanket
Systolic pressure

27. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Korotkoff sounds
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.
the lungs
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.

28. right arm vs. left arm/ arm vs. leg BP?
in the alveoli - tiny thin-walled sacs
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Vascular resistance drops and the blood pressure decreases

29. The average temperature in the older adult
popliteal
stridor
Stertor
96.5 to 97.5

30. Heart
Hyperventilation
Nursing interventions to reduce fever
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Apical

31. Weak and regular (even beats wit poor force)
+1
popliteal
120/70
palpate

32. Why would patients experience orthostatic hypotenstion?
Hypothermia
Korotkoff sounds
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.
from drug therapy - a neurologic problem or dehydration.

33. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
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.
Relapsing
carotid
low BP

34. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
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.
Hyperventilation
arrhythmia
30-80

35. Signs and symptoms of shock
Diastolic pressure
Increases as body tries to remove excess heat
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Stroke volume

36. How is shock caused?
Stroke volume
Korotkoff sounds Phase IV: Muffling
Kussmaul's respiration
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

37. What happens when vasodilation occurs?
Radial
Vascular resistance drops and the blood pressure decreases
Diaphoresis
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.

38. What affects does aging do to the respiratory rate?
hypoxia
Korotkoff sounds Phase II Swishing
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.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

39. Rectal temperature are
about 1 degree higher than oral temperatures
Acute anxiety stimulate the nervous system - raising the pulse.
Respiration
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

40. 3rd stage of fever?
Core Temperature
palpate
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

41. State of insufficient oxygen
Korotkoff sounds
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
hypoxia
the blood pressure will rise in order to push the blood along.

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

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43. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Evaporation
Stertor
16-20
60 to 70 mL

44. Side of neck
Pulse
carotid
The pulse rate gradually diminishes from birth to adulthood
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

45. Abrupt decline in fever
Korotkoff sounds Phase II Swishing
orthostatic hypertension
Systolic pressure
Crisis

46. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
Diastolic pressure
crackles
Posterior tibial
arrhythmia

47. Absence of breathing
Dorsalis pedis
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.
Cheyenne-Stokes
apnea

48. 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.
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.
crackles
Vascular resistance drops and the blood pressure decreases
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

49. Fast - deep respirations with abrupt pauses

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50. Axillary temperature are
uncooperative patient - children - combative patients - dementia
hypoxemia
wheeze
about 1 degree lower than oral temperatures

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Measuring Vital Signs

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