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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. Top of left foot
ausculatation
+2
Dorsalis pedis
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

2. What patients should not use a glass thermometer orally?
Axillary.
about 1 degree higher than oral temperatures
uncooperative patient - children - combative patients - dementia
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.

3. When the heart contracts How many mLs of blood is propelled into the aorta?
the blood pressure will rise in order to push the blood along.
oximetry
60 to 70 mL
men - African Americans - under a lot of stress - obese

4. Why would patients experience orthostatic hypotenstion?
dyspnea
tachycardia
from drug therapy - a neurologic problem or dehydration.
Convection

5. Barely palpable
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.
Feeble
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.
Cheyenne-Stokes

6. How do emotions increase the pulse rate?
72 bpm
12-20
Acute anxiety stimulate the nervous system - raising the pulse.
ausculatation

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

8. Full and bounding (even beats wit strong force)
+2
popliteal
the rate - the rhythm - and volume
+3

9. Normal body temperature ranges?
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
97.5 to 99.5
popliteal

10. Pulse above 100 beats per minute
bradycardia
tachycardia
absent
Pons and Medulla of the brainstem

11. Fever above 100.2 F
pyrexia
hypoxia
+3
thready

12. 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.
orthostatic hypertension
remittent
left Sims position
+1

13. Feel
Cardiac Output
+2
intermittent
palpate

14. Strong and regular ( even beats wit moderate force)
stridor
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
men - African Americans - under a lot of stress - obese
+2

15. Side of neck
97.5 to 99.5
carotid
3 in the right lung and 2 lobes in the left
left Sims position

16. Stage 2 hypertension
males have higher bp - until menopause then they are the same
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Blood pressure increases because there is more volume of blood in the vascular system.
^160/^100

17. How does age affect pulse?
lysis
The pulse rate gradually diminishes from birth to adulthood
60 to 70 mL
males have higher bp - until menopause then they are the same

18. Are infants blood pressure low or high?
uncooperative patient - children - combative patients - dementia
absent
low
carotid

19. What happens to the blood if overhydration occurs?
Blood pressure increases because there is more volume of blood in the vascular system.
60 to 70 mL
from drug therapy - a neurologic problem or dehydration.
Apical

20. 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.
3 in the right lung and 2 lobes in the left
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
30-80
Cardiac Output

21. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Stertor
30-80
hypoxia
Blood pressure increases because there is more volume of blood in the vascular system.

22. Risk for prolonged hypertension
ausculatation
Hypothermia
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Nursing interventions to reduce fever

23. Weak and may be irregular
Nursing interventions to reduce fever
30-80
Temperature will remain below 102 degrees with use of hypothermia blanket
thready

24. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
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.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
72 bpm
Acute anxiety stimulate the nervous system - raising the pulse.

25. Signs and symptoms of shock
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
absent
Posterior tibial
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.

26. How do drugs affect pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Convection
Feeble
12-20

27. Air movemtn causes heat to be transferred from the skin to the air molecules.
hypoxia
Korotkoff sounds
Convection
oximeter

28. How should respirations be counted?
Stroke volume
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
shallow or slow breathing
low

29. 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.
120/80
intermittent
Kussmaul's respiration

30. An example of a nursing diagnoses
120/80
crackles
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Hyperthermia related to infection or excessive heat exposure

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
Respiration
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

32. Inside ankle
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
3 in the right lung and 2 lobes in the left
Posterior tibial
+3

33. Excessive sweat production
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Korotkoff sounds Phase III: Knocking
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Diaphoresis

34. 3rd stage of fever?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
tachycardia
hypoxia
Axillary.

35. What should you do if you cannot determine BP by ausculation?
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
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
hypoxia

36. Elevated temperature
Korotkoff sounds Phase IV: Muffling
fever
higher
tachycardia

37. Fast - deep respirations with abrupt pauses

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38. Average pulse rate for an adult
72 bpm
about 1 degree lower than oral temperatures
Korotkoff sounds Phase IV: Muffling
Kussmaul's respiration

39. Taking a rectal temperature
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
120/80
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
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.

40. 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.
men - African Americans - under a lot of stress - obese
Pons and Medulla of the brainstem
Korotkoff sounds

41. Enviromental temperature BP?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
carotid
Korotkoff sounds Phase V: Silence
raises BP.

42. 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.
Core Temperature
about 1 degree lower than oral temperatures
hypoxemia
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

43. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
Sinoatrial node (SA NODE)
Respiration
Brachial

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

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45. Does the respiration rate increase or decrease during fever?
Hyperventilation
BMR
dyspnea
Increases as body tries to remove excess heat

46. How is pulse best found?
Blood pressure increases because there is more volume of blood in the vascular system.
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.
Eupnea
men - African Americans - under a lot of stress - obese

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

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48. Increased or rapid breathing results from te presence of fever and a number or diseases. breathing rate increased about 4 breaths for each degree increase in temperature.
about 1 degree higher than oral temperatures
Tachypnea
men - African Americans - under a lot of stress - obese
intermittent

49. High BP
hypertension
Feeble
higher
The emotions increase hormone secretion - and the body activities required for this increase heat production.

50. Bend of knee
popliteal
absent
Rhonchi
Conduction