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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. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Korotkoff sounds Phase V: Silence
intermittent
Pulse
Cardiac Output

2. Fast - deep respirations with abrupt pauses

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3. How is shock caused?
Evaporation
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Dorsalis pedis
Eupnea

4. Drop in blood pressure when arising to a standing position.
60 to 70 mL
orthostatic hypertension
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Nursing interventions to reduce fever

5. Normal body temperature ranges?
97.5 to 99.5
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
120/80
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.

6. What are the 5 vital signs?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
16-20
palpate
temperature - pulse - respiration - blood pressure - and pain level.

7. Groin area
low BP
Sinoatrial node (SA NODE)
140-159/90-99
Femoral

8. The temperature of the deep tissues of the body
men - African Americans - under a lot of stress - obese
Core Temperature
about 1 degree higher than oral temperatures
Increases as body tries to remove excess heat

9. What affects does aging do to the blood pressure?
BMR
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
wheeze
Systolic pressure

10. When should rectal temperatures be used?
hyperoxia
12-20
about 1 degree lower than oral temperatures
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

11. The average temperature in the older adult
palpate
fever
about 1 degree lower than oral temperatures
96.5 to 97.5

12. Whats the best position to take a rectal temperature?
Kussmaul's respiration
Stroke volume
oximetry
left Sims position

13. A normal - relaxed breathing pattern
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Brachial
Eupnea

14. Blood pressure for any adult should be no higher than
carotid
constant
120/80
the lungs

15. What affects does aging do to the respiratory rate?
Brachial
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
raises BP.
the rate - the rhythm - and volume

16. Slow and shallow breathing - leads to hypoxemia.
bradypnea
hypoxemia
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
oximetry

17. Weak and regular (even beats wit poor force)
+1
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Hypothermia
Pulse pressure

18. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
hypotension
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
oximeter

19. Barely palpable
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.
fever
The emotions increase hormone secretion - and the body activities required for this increase heat production.

20. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
140-159/90-99
Korotkoff sounds Phase IV: Muffling
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.
apnea

21. Healthly adult
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
12-20
palpate

22. Decreased levels of oxygen in the blood - often seen in patients wo are under medical sedation - who are recovering from anesthesia or abdominal surgery - or who are in a weak or debiliated condition.
pyrogens
120/70
3 in the right lung and 2 lobes in the left
hypoxemia

23. When is apicial pulse used?
the blood pressure will rise in order to push the blood along.
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.
constant
Pons and Medulla of the brainstem

24. Taking a rectal temperature
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.
Irregular
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.

25. Stage 2 hypertension
Apical
^160/^100
low
Acute anxiety stimulate the nervous system - raising the pulse.

26. How does external respiration occur?
intermittent
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
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.
16-20

27. How is pulse best found?
Korotkoff sounds Phase III: Knocking
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.
Korotkoff sounds Phase V: Silence
in the alveoli - tiny thin-walled sacs

28. Korotkoff sounds Ausculatatory gap:
lysis
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
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
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.

29. Sex BP?
males have higher bp - until menopause then they are the same
Stroke volume
16-20
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

30. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Biot's
Respiration
Posterior tibial

31. How should respirations be counted?
the rate - the rhythm - and volume
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Pons and Medulla of the brainstem
30-80

32. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Hyperthermia related to infection or excessive heat exposure
16-20
wheeze
about 1 degree lower than oral temperatures

33. Both strong and weak beats occur within 1 minute
Irregular
Relapsing
thready
+2

34. Taking axillary temperature
Pedal pulse
low
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.
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.

35. Air movemtn causes heat to be transferred from the skin to the air molecules.
hypotension
tachycardia
uncooperative patient - children - combative patients - dementia
Convection

36. Risk for prolonged hypertension
Korotkoff sounds Phase V: Silence
cardiac patients or patients who have had rectal surgery.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Kussmaul's respiration

37. The pulse rate multiplied by the stroke volume. This is the amount of blood pumped by the left ventricle in 1 minute. Averaging at about 5mL per minute.
Cardiac Output
60 to 70 mL
the lungs
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

38. Murmur or swishing sounds that increase as the cuff is deflated
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
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.
72 bpm
Korotkoff sounds Phase II Swishing

39. Lobes in the lungs?
higher
3 in the right lung and 2 lobes in the left
Axillary.
hypotension

40. Pulse above 100 beats per minute
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.
Korotkoff sounds Phase III: Knocking
tachycardia
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

41. Elevated temperature
intermittent
Radial
fever
ausculatation

42. Bend of knee
popliteal
Cardiac Output
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
30-80

43. 3 yr old
20-30
Diaphoresis
bradypnea
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

44. Side of forehead
Korotkoff sounds Phase III: Knocking
Stroke volume
Temporal
Blood pressure increases because there is more volume of blood in the vascular system.

45. How do drugs affect pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
140-159/90-99

46. 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.
Evaporation
20-30
Relapsing

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

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48. Rectal temperature are
about 1 degree higher than oral temperatures
16-20
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
It increases to push the blood through more rigid pathways.

49. Enviromental temperature BP?
+2
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
cardiac patients or patients who have had rectal surgery.

50. Head injury BP?
raises BP.
Cardiac Output
the lungs
Tachypnea

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Measuring Vital Signs

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