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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. Blood pressure for any adult should be no higher than
bradypnea
120/80
+2
apnea

2. How do emotions increase the pulse rate?
It will also fall
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.
fever

3. When warm skin touches a cool object - heat is lost to the object.
BMR
Conduction
shallow or slow breathing
palpate

4. Low oxygen
in the alveoli - tiny thin-walled sacs
hypoxia
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Respiration

5. Louder knocking sound that occurs wit each heartbeat
carotid
120/80
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.
Korotkoff sounds Phase III: Knocking

6. High BP
crackles
hypotension
hypertension
popliteal

7. A normal - relaxed breathing pattern
Hypothermia
hyperoxia
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Eupnea

8. Full and bounding (even beats wit strong force)
Pedal pulse
men - African Americans - under a lot of stress - obese
tachycardia
+3

9. 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
fever
Nursing interventions to reduce fever
72 bpm
Temporal

10. Measurement of oxygen
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Pulse
oximetry

11. How should baby's temperature be taken?
Axillary.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
about 1 degree lower than oral temperatures
20-30

12. How does external respiration occur?
96.5 to 97.5
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
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
ausculatation

13. Abrupt decline in fever
shallow or slow breathing
120/80
Crisis
It will also fall

14. When should rectal temperatures be used?
Temporal
Conduction
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 pressure

15. Stage 2 hypertension
^160/^100
Stertor
Relapsing
about 1 degree higher than oral temperatures

16. 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.
Blood pressure increases because there is more volume of blood in the vascular system.
97.5 to 99.5
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.

17. This affects the character of the pulse.
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
Eupnea
Stroke Volume

18. Breathing is an involuntary automatic function controlled by the respiratory center located where?
wheeze
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Pons and Medulla of the brainstem

19. Enviromental temperature BP?
^160/^100
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
16-20
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

20. Prehypertension
constant
Posterior tibial
pyrogens
120-139/80-89

21. The rate at which heat is produced when the body is at rest.
BMR
Hypothermia
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

22. How does age affect pulse?
The pulse rate gradually diminishes from birth to adulthood
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
remittent
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.

23. The average temperature in the older adult
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
Biot's
96.5 to 97.5
Hyperthermia related to infection or excessive heat exposure

24. Slow and shallow breathing - leads to hypoxemia.
hypoxia
hypoxia
bradypnea
hypoxemia

25. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
hypotension
the blood pressure will rise in order to push the blood along.
Cardiac Output
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

26. How do drugs affect pulse?
Apical
16-20
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Convection

27. High oxygen
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.
Radial
hyperoxia
low BP

28. If the cardiac output falls what will happen to the BP?
palpate
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
It will also fall
Stertor

29. By measuring the blood pressure you obtain vital info about what?
oximeter
72 bpm
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.
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. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
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.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Diaphoresis
dyspnea

31. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
It increases to push the blood through more rigid pathways.
Korotkoff sounds Phase IV: Muffling
96.5 to 97.5
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

32. 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.
hypoxia
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
crackles
Respiration

33. BP at or lower 90/60.
Kussmaul's respiration
hypertension
hypotension
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

34. 3 yr old
systolic pressure indicated by faint - clear sound that gradually grow louder.
shallow or slow breathing
20-30
low BP

35. 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
bradycardia
pyrexia
temperature - pulse - respiration - blood pressure - and pain level.
Hyperventilation

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

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37. Groin area
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Femoral
absent
Increases as body tries to remove excess heat

38. Elevated temperature
Femoral
fever
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
in the alveoli - tiny thin-walled sacs

39. How does emotional stress raise the body's temperature?
Relapsing
The pulse rate gradually diminishes from birth to adulthood
Vascular resistance drops and the blood pressure decreases
The emotions increase hormone secretion - and the body activities required for this increase heat production.

40. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
arrhythmia
left Sims position
Tall - slender people mayy ave a slower pulse rate than short - stout persons
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

41. Adolescent
Core Temperature
16-20
20-30
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.

42. How does menstrual cycle and pregnancy raise the body's temperature?
Diaphoresis
Korotkoff sounds Phase II Swishing
Diastolic pressure
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

43. Feel
palpate
Temporal
lysis
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.

44. Weak and may be irregular
bradypnea
thready
120/80
Pulse pressure

45. What happens when vasodilation occurs?
Stroke volume
bradypnea
Vascular resistance drops and the blood pressure decreases
Respiration

46. Bend of knee
Korotkoff sounds Phase IV: Muffling
in the alveoli - tiny thin-walled sacs
popliteal
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

47. What patients should not use a glass thermometer orally?
Feeble
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.
uncooperative patient - children - combative patients - dementia

48. What characteristics should be noted when checking the pulse?
Sinoatrial node (SA NODE)
Femoral
the rate - the rhythm - and volume
absent

49. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
3 in the right lung and 2 lobes in the left
oximeter
fever
constant

50. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
+1
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
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.