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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. Taking axillary temperature
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.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Irregular
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

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

3. Side of neck
thready
carotid
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.
+2

4. Substances tat cause fever
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Core Temperature
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
pyrogens

5. Diurnal variation BP?
It will also fall
tachycardia
blood pressure is lowest in the morning. and higher in the afternoone
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

6. Barely palpable
The pulse rate gradually diminishes from birth to adulthood
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.
60 to 70 mL
Feeble

7. Blood pressure for any adult should be no higher than
It will also fall
120/80
Pons and Medulla of the brainstem
Temporal

8. The average temperature in the older adult
96.5 to 97.5
30-80
shallow or slow breathing
Stroke volume

9. Both strong and weak beats occur within 1 minute
Irregular
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
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
30-80

10. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Korotkoff sounds Phase IV: Muffling
about 1 degree lower than oral temperatures
Systolic pressure
+2

11. Stress & emotions. BP?
Korotkoff sounds
bradypnea
higher
pyrexia

12. BP at or lower 90/60.
Radial
hypotension
Hypothermia
Tall - slender people mayy ave a slower pulse rate than short - stout persons

13. How does age affect pulse?
The pulse rate gradually diminishes from birth to adulthood
dyspnea
Apical
Stroke volume

14. Breathing is an involuntary automatic function controlled by the respiratory center located where?
hypotension
Pons and Medulla of the brainstem
about 1 degree lower than oral temperatures
pyrexia

15. Newborn
the rate - the rhythm - and volume
30-80
Core Temperature
popliteal

16. What are the 5 vital signs?
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.
temperature - pulse - respiration - blood pressure - and pain level.
120/70
low BP

17. When is apicial pulse used?
It increases to push the blood through more rigid pathways.
left Sims position
30-80
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.

18. 3 yr old
20-30
The pulse rate gradually diminishes from birth to adulthood
Apical
Increases as body tries to remove excess heat

19. Stage 2 hypertension
Korotkoff sounds Phase IV: Muffling
+3
96.5 to 97.5
^160/^100

20. Drop in blood pressure when arising to a standing position.
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.
Pons and Medulla of the brainstem
BMR
orthostatic hypertension

21. 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
12-20
Rhonchi
Hyperventilation
Korotkoff sounds Phase IV: Muffling

22. The temperature falls to normal and then rises again in a repeating pattern.
Vascular resistance drops and the blood pressure decreases
Relapsing
Korotkoff sounds Phase II Swishing
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

23. Slow and shallow breathing - leads to hypoxemia.
the rate - the rhythm - and volume
lysis
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
bradypnea

24. Low oxygen
+3
hypoxia
orthostatic hypertension
pyrexia

25. Weak and may be irregular
thready
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
3 in the right lung and 2 lobes in the left
bradypnea

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

27. How should baby's temperature be taken?
Axillary.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
96.5 to 97.5
in the alveoli - tiny thin-walled sacs

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

29. Why would patients experience orthostatic hypotenstion?
temperature - pulse - respiration - blood pressure - and pain level.
lysis
+3
from drug therapy - a neurologic problem or dehydration.

30. Korotkoff sounds Ausculatatory gap:
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Temperature will remain below 102 degrees with use of hypothermia blanket
30-80
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

31. Inside ankle
Posterior tibial
Core Temperature
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
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

32. Measurement of oxygen
pyrogens
Conduction
oximetry
temperature - pulse - respiration - blood pressure - and pain level.

33. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
dyspnea
the rate - the rhythm - and volume
constant
Systolic pressure

34. What affects does aging do to the blood pressure?
3 in the right lung and 2 lobes in the left
intermittent
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
higher

35. right arm vs. left arm/ arm vs. leg BP?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
the rate - the rhythm - and volume
Crisis
+2

36. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
hypoxia
constant
shallow or slow breathing
males have higher bp - until menopause then they are the same

37. How does size affect pulse?
hypoxia
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Tall - slender people mayy ave a slower pulse rate than short - stout persons

38. When should rectal temperatures NOT be used?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
cardiac patients or patients who have had rectal surgery.
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.
men - African Americans - under a lot of stress - obese

39. What happens when vasodilation occurs?
Vascular resistance drops and the blood pressure decreases
higher
intermittent
Hypothermia

40. Louder knocking sound that occurs wit each heartbeat
about 1 degree higher than oral temperatures
Korotkoff sounds Phase III: Knocking
Brachial
Korotkoff sounds Phase V: Silence

41. 2nd stage of fever is?
orthostatic hypertension
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.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Temperature will remain below 102 degrees with use of hypothermia blanket

42. Signs and symptoms of shock
120/80
Increases as body tries to remove excess heat
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
left Sims position

43. How cardiac contractions are normally initiated by the electrical impules emerging from what?
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.
Sinoatrial node (SA NODE)
Femoral
Nursing interventions to reduce fever

44. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
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.
absent
+1

45. 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
remittent
120/70
Pedal pulse
Irregular

46. Bend of knee
popliteal
carotid
Stertor
apnea

47. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
blood pressure is lowest in the morning. and higher in the afternoone
Korotkoff sounds Phase II Swishing
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Cheyenne-Stokes

48. Heart
3 in the right lung and 2 lobes in the left
cardiac patients or patients who have had rectal surgery.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Apical

49. Symptoms of hypoxia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
about 1 degree lower than oral temperatures
raises BP.
30-80

50. High oxygen
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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.
Nursing interventions to reduce fever
hyperoxia