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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. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Korotkoff sounds
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.
about 1 degree lower than oral temperatures

2. The difference between the systolic pressure and the diastolic pressure
12-20
males have higher bp - until menopause then they are the same
Pulse pressure
Dorsalis pedis

3. The average temperature in the older adult
96.5 to 97.5
Axillary.
Korotkoff sounds
males have higher bp - until menopause then they are the same

4. Gradual return to a normal temperature
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
lysis
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Cardiac Output

5. Signs and symptoms of shock
oximeter
hypertension
Hyperventilation
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

6. Adolescent
absent
Korotkoff sounds Phase III: Knocking
3 in the right lung and 2 lobes in the left
16-20

7. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
97.5 to 99.5
96.5 to 97.5
Diastolic pressure

8. How does size affect pulse?
Irregular
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.
hypoxemia
Tall - slender people mayy ave a slower pulse rate than short - stout persons

9. The temperature of the deep tissues of the body
+1
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Acute anxiety stimulate the nervous system - raising the pulse.
Core Temperature

10. Subnormal body temperature the regulating center in the hypothalamus is greatly impaired when the temperature of the body falls below 94 degrees - at that point? sleepiness and coma are apt to develop.
Systolic pressure
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Hypothermia
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

11. Absence of breathing
Core Temperature
apnea
+1
Irregular

12. When is apicial pulse used?
shallow or slow breathing
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
about 1 degree lower than oral temperatures
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.

13. Weak and regular (even beats wit poor force)
tachycardia
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
+1
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

14. Alternating rise and fall of the temperature.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Pons and Medulla of the brainstem
intermittent
Posterior tibial

15. Stress & emotions. BP?
Korotkoff sounds Phase II Swishing
low
higher
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

16. Stage 1 hypertension
the lungs
temperature - pulse - respiration - blood pressure - and pain level.
140-159/90-99
Hypothermia

17. How does physical exercise raise the body's 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.
ausculatation
Nursing interventions to reduce fever
uncooperative patient - children - combative patients - dementia

18. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
140-159/90-99
Evaporation
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.
hypoxemia

19. 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.
Temperature will remain below 102 degrees with use of hypothermia blanket
Relapsing
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

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

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21. Groin area
Femoral
Axillary.
Eupnea
BMR

22. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
left Sims position
Stertor
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Convection

23. Those at risk for hypothermia include
systolic pressure indicated by faint - clear sound that gradually grow louder.
Pulse
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.
Biot's respirations

24. Healthly adult
3 in the right lung and 2 lobes in the left
hypoxia
Sinoatrial node (SA NODE)
12-20

25. Gas exchange in the blood occurs where?
in the alveoli - tiny thin-walled sacs
120/70
120-139/80-89
intermittent

26. Risk for prolonged hypertension
The emotions increase hormone secretion - and the body activities required for this increase heat production.
hyperoxia
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

27. Disappearance of sound. (marks diastolic pressure in adults)
Pulse pressure
bradycardia
Korotkoff sounds Phase V: Silence
Tachypnea

28. The maximum pressure exerted on the artery during left ventricular contraction.
Systolic pressure
temperature - pulse - respiration - blood pressure - and pain level.
males have higher bp - until menopause then they are the same
120/80

29. Both strong and weak beats occur within 1 minute
Temporal
Axillary.
Irregular
Hyperthermia related to infection or excessive heat exposure

30. Bend of elbow
120/70
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.
Brachial
oximeter

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

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32. 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
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.
orthostatic hypertension
Nursing interventions to reduce fever
arrhythmia

33. How does external respiration occur?
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.
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
16-20
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

34. Difference between the apical and radial pulse - this requires two people to count the radial and apicial pulses at the same time to determine whether there is a what?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
absent
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
hypoxia

35. High BP
20-30
Relapsing
hypertension
Temperature will remain below 102 degrees with use of hypothermia blanket

36. Does the respiration rate increase or decrease during fever?
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Increases as body tries to remove excess heat
Radial
uncooperative patient - children - combative patients - dementia

37. What affects does aging do to the respiratory rate?
hypertension
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
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

38. Elderly respiration
16-20
uncooperative patient - children - combative patients - dementia
Radial
oximeter

39. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
Cheyenne-Stokes
Blood pressure increases because there is more volume of blood in the vascular system.
It increases to push the blood through more rigid pathways.
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.

40. Excessive sweat production
30-80
Conduction
Diaphoresis
Cheyenne-Stokes

41. Air movemtn causes heat to be transferred from the skin to the air molecules.
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.
+3
Convection
Korotkoff sounds Phase III: Knocking

42. How should baby's temperature be taken?
Relapsing
Axillary.
Vascular resistance drops and the blood pressure decreases
shallow or slow breathing

43. Head injury BP?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
dyspnea
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.
raises BP.

44. Side of forehead
+1
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Temporal

45. Fast - deep respirations with abrupt pauses

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46. Symptoms of hypoxia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Dorsalis pedis
Cardiac Output

47. What happens to the blood if overhydration occurs?
The pulse rate gradually diminishes from birth to adulthood
Radial
Stroke volume
Blood pressure increases because there is more volume of blood in the vascular system.

48. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
Evaporation
remittent
low BP
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.

49. right arm vs. left arm/ arm vs. leg BP?
the blood pressure will rise in order to push the blood along.
72 bpm
dyspnea
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

50. Whats the best position to take a rectal temperature?
16-20
left Sims position
Korotkoff sounds Phase IV: Muffling
Hyperventilation