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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. Rectal temperature are
about 1 degree higher than oral temperatures
BMR
The pulse rate gradually diminishes from birth to adulthood
Biot's

2. Groin area
Temporal
Femoral
Cardiac Output
Nursing interventions to reduce fever

3. Side of neck
orthostatic hypertension
about 1 degree lower than oral temperatures
carotid
Convection

4. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Axillary.
Pons and Medulla of the brainstem
12-20

5. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
dyspnea
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.
+3
crackles

6. Side of forehead
120-139/80-89
Increases as body tries to remove excess heat
Temporal
blood pressure is lowest in the morning. and higher in the afternoone

7. 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.
uncooperative patient - children - combative patients - dementia
Hypothermia
hypertension
Axillary.

8. How do you measure the apical pulse?
hypotension
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.
hypoxia
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

9. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Crisis
Pulse
30-80

10. Enviromental temperature BP?
hypotension
^160/^100
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Blood pressure increases because there is more volume of blood in the vascular system.

11. Pulse lower than 60 beats per minute
bradycardia
^160/^100
BMR
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.

12. 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
Axillary.
72 bpm
20-30
Nursing interventions to reduce fever

13. Gradual return to a normal temperature
lysis
Stertor
tachycardia
the blood pressure will rise in order to push the blood along.

14. Absence of breathing
120-139/80-89
apnea
Axillary.
72 bpm

15. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
Tachypnea
stridor
hyperoxia
shallow or slow breathing

16. How does physical exercise raise the body's temperature?
Cardiac Output
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.
low BP
Sinoatrial node (SA NODE)

17. Bend of knee
popliteal
Systolic pressure
oximeter
Temperature will remain below 102 degrees with use of hypothermia blanket

18. Full and bounding (even beats wit strong force)
wheeze
Diaphoresis
uncooperative patient - children - combative patients - dementia
+3

19. The rate at which heat is produced when the body is at rest.
^160/^100
Increases as body tries to remove excess heat
carotid
BMR

20. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
ausculatation
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
Evaporation
cardiac patients or patients who have had rectal surgery.

21. Substances tat cause fever
Stroke volume
pyrogens
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Nursing interventions to reduce fever

22. How is pulse best found?
Pedal pulse
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
16-20
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.

23. Axillary temperature are
Crisis
Nursing interventions to reduce fever
about 1 degree lower than oral temperatures
low BP

24. An example of a nursing diagnoses
The emotions increase hormone secretion - and the body activities required for this increase heat production.
^160/^100
+3
Hyperthermia related to infection or excessive heat exposure

25. What characteristics should be noted when checking the pulse?
+1
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.
the rate - the rhythm - and volume
Brachial

26. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
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
hypoxia
Stertor

27. Healthly adult
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
12-20
hypoxia
about 1 degree lower than oral temperatures

28. Alternating rise and fall of the temperature.
Hyperventilation
hypoxia
intermittent
constant

29. No pulse palpable or heard on ausculation
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 II Swishing
BMR
absent

30. Disappearance of sound. (marks diastolic pressure in adults)
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Crisis
Korotkoff sounds Phase V: Silence
men - African Americans - under a lot of stress - obese

31. What happens to the blood if overhydration occurs?
oximeter
Blood pressure increases because there is more volume of blood in the vascular system.
hypoxia
oximetry

32. 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.
Korotkoff sounds Phase V: Silence
Biot's respirations
from drug therapy - a neurologic problem or dehydration.
remittent

33. What affects does aging do to the blood pressure?
Stertor
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
the rate - the rhythm - and volume
BMR

34. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Korotkoff sounds Phase IV: Muffling
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Sinoatrial node (SA NODE)
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

35. When the heart contracts How many mLs of blood is propelled into the aorta?
Axillary.
60 to 70 mL
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
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.

36. Top of left foot
uncooperative patient - children - combative patients - dementia
Dorsalis pedis
60 to 70 mL
Pedal pulse

37. How is shock caused?
arrhythmia
12-20
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
absent

38. How should respirations be counted?
raises BP.
Temperature will remain below 102 degrees with use of hypothermia blanket
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
males have higher bp - until menopause then they are the same

39. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
Pulse
96.5 to 97.5
Stroke volume
low BP

40. Slow and shallow breathing - leads to hypoxemia.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
bradypnea
stridor
It increases to push the blood through more rigid pathways.

41. Louder knocking sound that occurs wit each heartbeat
Temporal
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
wheeze
Korotkoff sounds Phase III: Knocking

42. When should rectal temperatures NOT be used?
16-20
cardiac patients or patients who have had rectal surgery.
Cheyenne-Stokes
60 to 70 mL

43. Blood pressure for any adult should be no higher than
120/80
hypoxia
arrhythmia
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.

44. How does size affect pulse?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Korotkoff sounds Phase IV: Muffling
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.
pyrexia

45. Fever above 100.2 F
Tachypnea
hypoxia
pyrexia
Kussmaul's respiration

46. What should you do if you cannot determine BP by ausculation?
hypertension
apnea
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.
blood pressure is lowest in the morning. and higher in the afternoone

47. Side of wrist
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.
Radial
Brachial
Nursing interventions to reduce fever

48. The volume of blood pushed into the aorta per heartbeat.
Femoral
oximeter
Sinoatrial node (SA NODE)
Stroke volume

49. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
arrhythmia
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.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

50. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
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.
hypoxia
from drug therapy - a neurologic problem or dehydration.
It increases to push the blood through more rigid pathways.