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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
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. How does emotional stress raise the body's temperature?
Sinoatrial node (SA NODE)
Cheyenne-Stokes
left Sims position
The emotions increase hormone secretion - and the body activities required for this increase heat production.

2. Side of forehead
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
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
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
Temporal

3. How is pulse best found?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
popliteal
3 in the right lung and 2 lobes in the left
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.

4. What affects does aging do to the blood pressure?
hypotension
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
palpate
blood pressure is lowest in the morning. and higher in the afternoone

5. Bend of knee
Radial
bradypnea
Korotkoff sounds Phase V: Silence
popliteal

6. 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
wheeze
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
stridor

7. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
oximetry
wheeze
fever
higher

8. 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
Hypothermia
low BP
lysis
Nursing interventions to reduce fever

9. Taking axillary temperature
constant
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.
Systolic pressure
hypoxemia

10. Fast - deep respirations with abrupt pauses

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11. Side of wrist
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
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Radial
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

12. Elderly respiration
16-20
Pons and Medulla of the brainstem
Diaphoresis
Korotkoff sounds Phase IV: Muffling

13. 3 yr old
shallow or slow breathing
20-30
apnea
Axillary.

14. Gradual return to a normal temperature
hypotension
lysis
Diastolic pressure
Tachypnea

15. People most at risk for hypertension
Irregular
men - African Americans - under a lot of stress - obese
Crisis
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

16. An example of a nursing diagnoses
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
popliteal
Hyperthermia related to infection or excessive heat exposure
The emotions increase hormone secretion - and the body activities required for this increase heat production.

17. BP at or lower 90/60.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
hypoxemia
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
hypotension

18. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
^160/^100
the lungs
Korotkoff sounds Phase V: Silence

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

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20. Feel
palpate
140-159/90-99
Temperature will remain below 102 degrees with use of hypothermia blanket
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

21. Blood pressure for any adult should be no higher than
120/80
Posterior tibial
Acute anxiety stimulate the nervous system - raising the pulse.
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.

22. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
Pons and Medulla of the brainstem
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
stridor
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

23. Weak and may be irregular
thready
Tachypnea
The emotions increase hormone secretion - and the body activities required for this increase heat production.
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.

24. How do emotions increase the pulse rate?
It will also fall
Acute anxiety stimulate the nervous system - raising the pulse.
oximeter
thready

25. Pulse lower than 60 beats per minute
Sinoatrial node (SA NODE)
Pons and Medulla of the brainstem
Systolic pressure
bradycardia

26. The maximum pressure exerted on the artery during left ventricular contraction.
140-159/90-99
Systolic pressure
hypoxia
intermittent

27. Strong and regular ( even beats wit moderate force)
Irregular
+2
Tall - slender people mayy ave a slower pulse rate than short - stout persons
hypotension

28. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
It will also fall
Increases as body tries to remove excess heat
Eupnea
Korotkoff sounds Phase IV: Muffling

29. right arm vs. left arm/ arm vs. leg BP?
Acute anxiety stimulate the nervous system - raising the pulse.
Posterior tibial
Biot's
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

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

31. Murmur or swishing sounds that increase as the cuff is deflated
20-30
Korotkoff sounds Phase II Swishing
Apical
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

32. How do you measure the apical pulse?
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
Diaphoresis
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
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

33. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
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.
140-159/90-99
Diastolic pressure
the lungs

34. Abrupt decline in fever
Crisis
about 1 degree higher than oral temperatures
higher
Hyperventilation

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

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36. How does menstrual cycle and pregnancy raise the body's temperature?
the lungs
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
pyrogens
Biot's

37. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Acute anxiety stimulate the nervous system - raising the pulse.
Evaporation
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

38. Whats the best position to take a rectal temperature?
96.5 to 97.5
left Sims position
Rhonchi
uncooperative patient - children - combative patients - dementia

39. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
temperature - pulse - respiration - blood pressure - and pain level.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Apical

40. What characteristics should be noted when checking the pulse?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
It will also fall
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
the rate - the rhythm - and volume

41. Stress & emotions. BP?
Feeble
thready
higher
hypoxia

42. 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.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

43. Drop in blood pressure when arising to a standing position.
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.
from drug therapy - a neurologic problem or dehydration.
orthostatic hypertension
hypoxia

44. 2nd stage of fever is?
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.
12-20
Pulse
popliteal

45. An example of nursing planning
Temperature will remain below 102 degrees with use of hypothermia blanket
120/80
hypoxemia
Irregular

46. Why would patients experience orthostatic hypotenstion?
thready
Apical
from drug therapy - a neurologic problem or dehydration.
Vascular resistance drops and the blood pressure decreases

47. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
arrhythmia
Systolic pressure
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
lysis

48. 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.
Dorsalis pedis
Irregular
fever
hypoxemia

49. Obtaining the correct size for a cuff for BP?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Respiration
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
shallow or slow breathing

50. Side of neck
carotid
Korotkoff sounds Phase II Swishing
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
men - African Americans - under a lot of stress - obese