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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. What happens when vasodilation occurs?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Acute anxiety stimulate the nervous system - raising the pulse.
Vascular resistance drops and the blood pressure decreases
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.

2. Weak and may be irregular
oximetry
from drug therapy - a neurologic problem or dehydration.
thready
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

3. BP at or lower 90/60.
thready
hypotension
from drug therapy - a neurologic problem or dehydration.
Acute anxiety stimulate the nervous system - raising the pulse.

4. Drop in blood pressure when arising to a standing position.
It increases to push the blood through more rigid pathways.
Kussmaul's respiration
Nursing interventions to reduce fever
orthostatic hypertension

5. When warm skin touches a cool object - heat is lost to the object.
Conduction
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
72 bpm
It increases to push the blood through more rigid pathways.

6. Excessive sweat production
Diaphoresis
about 1 degree lower than oral temperatures
Temporal
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

7. Disappearance of sound. (marks diastolic pressure in adults)
Hyperthermia related to infection or excessive heat exposure
Korotkoff sounds Phase V: Silence
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
dyspnea

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

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9. Inside ankle
Blood pressure increases because there is more volume of blood in the vascular system.
Posterior tibial
Conduction
60 to 70 mL

10. Symptoms of hypoxia
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.
120/70
shallow or slow breathing
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

11. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Respiration
72 bpm
3 in the right lung and 2 lobes in the left
It increases to push the blood through more rigid pathways.

12. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
72 bpm
Pedal pulse
wheeze
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.

13. How do drugs affect pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
hypotension
palpate

14. Korotkoff sounds Phase I: Tapping
systolic pressure indicated by faint - clear sound that gradually grow louder.
dyspnea
Rhonchi
Korotkoff sounds Phase IV: Muffling

15. How should respirations be counted?
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
hypoxemia
apnea
Crisis

16. Both strong and weak beats occur within 1 minute
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
Irregular
palpate
tachycardia

17. Full and bounding (even beats wit strong force)
Tachypnea
Hypothermia
+3
temperature - pulse - respiration - blood pressure - and pain level.

18. Taking axillary temperature
stridor
intermittent
Systolic pressure
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.

19. 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.
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
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Tall - slender people mayy ave a slower pulse rate than short - stout persons

20. Fast - deep respirations with abrupt pauses

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21. Side of neck
12-20
Irregular
Dorsalis pedis
carotid

22. Top of left foot
Pedal pulse
Diastolic pressure
shallow or slow breathing
Dorsalis pedis

23. Bend of elbow
Brachial
Convection
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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

24. 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
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Hyperventilation
Sinoatrial node (SA NODE)
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

25. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
It increases to push the blood through more rigid pathways.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Pulse pressure
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.

26. Fever above 100.2 F
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.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
pyrexia
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.

27. Absence of breathing
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
Core Temperature
apnea
Hypothermia

28. The rate at which heat is produced when the body is at rest.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
BMR
120/70

29. 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
Stertor
bradycardia
Apical

30. How should baby's temperature be taken?
Axillary.
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
Crisis
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

31. Why would patients experience orthostatic hypotenstion?
from drug therapy - a neurologic problem or dehydration.
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
Relapsing
Stertor

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

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33. Abrupt decline in fever
Cardiac Output
Crisis
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly 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

34. Those at risk for hypothermia include
Korotkoff sounds Phase IV: Muffling
pyrexia
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 palpation method is used. put cuff over arm - feel the radial point to get the systolic pressure you cant get the diastolic this way.

35. Groin area
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
shallow or slow breathing
oximetry
Femoral

36. Weak and regular (even beats wit poor force)
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Sinoatrial node (SA NODE)
left Sims position
+1

37. How is pulse best found?
lysis
Nursing interventions to reduce fever
Hyperthermia related to infection or excessive heat exposure
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.

38. What characteristics should be noted when checking the pulse?
the rate - the rhythm - and volume
in the alveoli - tiny thin-walled sacs
97.5 to 99.5
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.

39. Measurement of oxygen
^160/^100
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
oximetry
Diaphoresis

40. High oxygen
wheeze
remittent
hyperoxia
30-80

41. Pulse above 100 beats per minute
Biot's
tachycardia
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.
3 in the right lung and 2 lobes in the left

42. The maximum pressure exerted on the artery during left ventricular contraction.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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.
BMR
Systolic pressure

43. An example of nursing planning
Temperature will remain below 102 degrees with use of hypothermia blanket
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Korotkoff sounds Phase IV: Muffling
Temporal

44. Signs and symptoms of shock
Rhonchi
97.5 to 99.5
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
72 bpm

45. Gas exchange in the blood occurs where?
Diastolic pressure
Dorsalis pedis
lysis
in the alveoli - tiny thin-walled sacs

46. 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.
crackles
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Stroke volume
Korotkoff sounds Phase II Swishing

47. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
shallow or slow breathing
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Axillary.
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

48. 3 yr old
oximeter
tachycardia
Stertor
20-30

49. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
absent
30-80
Stertor
Temporal

50. Low oxygen
Vascular resistance drops and the blood pressure decreases
hypoxia
pyrexia
Tachypnea