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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. Enviromental temperature BP?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
^160/^100
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
+3

2. Inside ankle
Posterior tibial
about 1 degree lower than oral temperatures
Korotkoff sounds Phase V: Silence
3 in the right lung and 2 lobes in the left

3. Feel
Feeble
palpate
orthostatic hypertension
hypoxia

4. 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.
remittent
fever
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.
popliteal

5. Taking a rectal temperature
fever
Diastolic pressure
about 1 degree higher than oral temperatures
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

6. 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.
The pulse rate gradually diminishes from birth to adulthood
crackles
tachycardia
12-20

7. The difference between the systolic pressure and the diastolic pressure
males have higher bp - until menopause then they are the same
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Hypothermia
Pulse pressure

8. 3rd stage of fever?
Biot's respirations
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Korotkoff sounds Phase IV: Muffling
Blood pressure increases because there is more volume of blood in the vascular system.

9. What characteristics should be noted when checking the pulse?
fever
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
tachycardia
the rate - the rhythm - and volume

10. Bend of elbow
60 to 70 mL
120/80
Brachial
16-20

11. What happens to the blood if overhydration occurs?
72 bpm
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
fever
Blood pressure increases because there is more volume of blood in the vascular system.

12. Signs and symptoms of shock
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
140-159/90-99
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Relapsing

13. Pulse lower than 60 beats per minute
Korotkoff sounds Phase V: Silence
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.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
bradycardia

14. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
thready
apnea
12-20
Cheyenne-Stokes

15. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
Sinoatrial node (SA NODE)
males have higher bp - until menopause then they are the same
cardiac patients or patients who have had rectal surgery.

16. Stage 1 hypertension
the blood pressure will rise in order to push the blood along.
Core Temperature
140-159/90-99
bradypnea

17. When the heart contracts How many mLs of blood is propelled into the aorta?
Acute anxiety stimulate the nervous system - raising the pulse.
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.
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

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

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19. BP at or lower 90/60.
intermittent
hypotension
Biot's respirations
carotid

20. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Core Temperature
Korotkoff sounds
Pulse
left Sims position

21. By measuring the blood pressure you obtain vital info about what?
Posterior tibial
in the alveoli - tiny thin-walled sacs
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
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.

22. Rectal temperature are
shallow or slow breathing
about 1 degree higher than oral temperatures
popliteal
120-139/80-89

23. How do you measure the apical pulse?
+3
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
Feeble
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.

24. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
Tachypnea
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.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
males have higher bp - until menopause then they are the same

25. Bend of knee
Pulse
popliteal
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
Biot's

26. Side of forehead
Temporal
thready
Eupnea
bradycardia

27. right arm vs. left arm/ arm vs. leg BP?
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.
low BP
Nursing interventions to reduce fever
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

28. Abrupt decline in fever
96.5 to 97.5
Crisis
Eupnea
12-20

29. Elevated temperature
fever
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.
ausculatation
stridor

30. How do drugs affect pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Pulse pressure
Acute anxiety stimulate the nervous system - raising the pulse.
about 1 degree lower than oral temperatures

31. 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
Nursing interventions to reduce fever
hypoxia
palpate
Diaphoresis

32. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Temperature will remain below 102 degrees with use of hypothermia blanket
wheeze
^160/^100
from drug therapy - a neurologic problem or dehydration.

33. Side of neck
Radial
about 1 degree lower than oral temperatures
carotid
intermittent

34. What patients should not use a glass thermometer orally?
fever
The pulse rate gradually diminishes from birth to adulthood
+1
uncooperative patient - children - combative patients - dementia

35. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
thready
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.

36. How does emotional stress raise the body's temperature?
Korotkoff sounds Phase IV: Muffling
Femoral
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Increases as body tries to remove excess heat

37. Axillary temperature are
bradycardia
Korotkoff sounds Phase V: Silence
about 1 degree lower than oral temperatures
Stroke Volume

38. How does increased body temperature increase the pulse?
20-30
from drug therapy - a neurologic problem or dehydration.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Tall - slender people mayy ave a slower pulse rate than short - stout persons

39. Groin area
popliteal
30-80
96.5 to 97.5
Femoral

40. The rate at which heat is produced when the body is at rest.
BMR
120/70
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
pyrexia

41. 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.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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
Hypothermia

42. 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.
Tachypnea
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
popliteal

43. Fast - deep respirations with abrupt pauses

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44. High oxygen
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
bradypnea
hyperoxia
Stroke volume

45. Weak and may be irregular
Brachial
thready
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Stroke Volume

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

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47. When is apicial pulse used?
stridor
Pulse
oximeter
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.

48. Adolescent
Korotkoff sounds Phase V: Silence
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.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
16-20

49. Average pulse rate for an adult
72 bpm
140-159/90-99
systolic pressure indicated by faint - clear sound that gradually grow louder.
uncooperative patient - children - combative patients - dementia

50. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Pedal pulse
Korotkoff sounds Phase IV: Muffling
hyperoxia
Cardiac Output