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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. Stress & emotions. BP?
higher
left Sims position
hypotension
Core Temperature

2. How do emotions increase the pulse rate?
Acute anxiety stimulate the nervous system - raising the pulse.
Hypothermia
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.
about 1 degree lower than oral temperatures

3. Taking axillary temperature
orthostatic hypertension
Convection
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.
men - African Americans - under a lot of stress - obese

4. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Pons and Medulla of the brainstem
Korotkoff sounds
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Diastolic pressure

5. Excessive sweat production
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Diaphoresis
Pons and Medulla of the brainstem
60 to 70 mL

6. Heart
Apical
shallow or slow breathing
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

7. Weak and may be irregular
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Pulse
thready
bradycardia

8. What affects does aging do to the blood pressure?
96.5 to 97.5
shallow or slow breathing
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
low

9. Bend of elbow
shallow or slow breathing
+1
3 in the right lung and 2 lobes in the left
Brachial

10. Low oxygen
The emotions increase hormone secretion - and the body activities required for this increase heat production.
96.5 to 97.5
hypoxia
Temporal

11. The maximum pressure exerted on the artery during left ventricular contraction.
left Sims position
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Increases as body tries to remove excess heat
Systolic pressure

12. Stage 2 hypertension
Korotkoff sounds Phase V: Silence
^160/^100
Feeble
the blood pressure will rise in order to push the blood along.

13. Elderly respiration
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Nursing interventions to reduce fever
16-20
Axillary.

14. Stage 1 hypertension
Evaporation
96.5 to 97.5
140-159/90-99
apnea

15. How do you measure the apical pulse?
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.
Stroke Volume
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
Dorsalis pedis

16. The temperature of the deep tissues of the body
palpate
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Femoral
Core Temperature

17. The volume of blood pushed into the aorta per heartbeat.
Stroke volume
crackles
It increases to push the blood through more rigid pathways.
tachycardia

18. How should baby's temperature be taken?
orthostatic hypertension
men - African Americans - under a lot of stress - obese
Axillary.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

19. Feel
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
palpate
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
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.

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

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21. Louder knocking sound that occurs wit each heartbeat
Stroke Volume
Korotkoff sounds Phase III: Knocking
Kussmaul's respiration
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

22. High oxygen
Axillary.
hyperoxia
shallow or slow breathing
Blood pressure increases because there is more volume of blood in the vascular system.

23. Gradual return to a normal temperature
Korotkoff sounds Phase II Swishing
Korotkoff sounds
lysis
palpate

24. Weak and regular (even beats wit poor force)
3 in the right lung and 2 lobes in the left
Dorsalis pedis
+1
20-30

25. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
Hypothermia
Diastolic pressure
60 to 70 mL
Crisis

26. Risk for prolonged hypertension
the rate - the rhythm - and volume
intermittent
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
oximetry

27. Side of wrist
120/70
Temporal
Radial
temperature - pulse - respiration - blood pressure - and pain level.

28. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
systolic pressure indicated by faint - clear sound that gradually grow louder.
Stertor
popliteal
Hypothermia

29. Obtaining the correct size for a cuff for BP?
The pulse rate gradually diminishes from birth to adulthood
Korotkoff sounds Phase IV: Muffling
Hyperthermia related to infection or excessive heat exposure
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

30. High BP
Pedal pulse
hypertension
Cheyenne-Stokes
apnea

31. Substances tat cause fever
30-80
pyrogens
Hyperthermia related to infection or excessive heat exposure
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

32. The average temperature in the older adult
96.5 to 97.5
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Core Temperature
orthostatic hypertension

33. This affects the character of the pulse.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
120/70
Stroke Volume
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.

34. What should you do if you cannot determine BP by ausculation?
ausculatation
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.
apnea
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

35. Top of left foot
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
about 1 degree lower than oral temperatures
Dorsalis pedis
Pedal pulse

36. Inside ankle
Posterior tibial
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
wheeze
dyspnea

37. 3rd stage of fever?
Eupnea
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
men - African Americans - under a lot of stress - obese

38. Alternating rise and fall of the temperature.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
intermittent
shallow or slow breathing
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. Korotkoff sounds Ausculatatory gap:
Irregular
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Systolic pressure
Korotkoff sounds Phase III: Knocking

40. Disappearance of sound. (marks diastolic pressure in adults)
16-20
Hypothermia
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

41. Strong and regular ( even beats wit moderate force)
hypoxia
+2
popliteal
pyrexia

42. Bend of knee
Nursing interventions to reduce fever
Korotkoff sounds Phase III: Knocking
cardiac patients or patients who have had rectal surgery.
popliteal

43. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
blood pressure is lowest in the morning. and higher in the afternoone
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
about 1 degree higher than oral temperatures
higher

44. Fever above 100.2 F
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
pyrexia
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Biot's

45. Measurement of oxygen
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
oximetry
bradypnea
about 1 degree higher than oral temperatures

46. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
dyspnea
low BP
12-20
blood pressure is lowest in the morning. and higher in the afternoone

47. BP at or lower 90/60.
the lungs
Nursing interventions to reduce fever
hypotension
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. 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.
oximeter
crackles
Cheyenne-Stokes
Core Temperature

49. When should rectal temperatures NOT be used?
Increases as body tries to remove excess heat
cardiac patients or patients who have had rectal surgery.
low
the rate - the rhythm - and volume

50. How does age affect pulse?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
The pulse rate gradually diminishes from birth to adulthood
blood pressure is lowest in the morning. and higher in the afternoone
Dorsalis pedis

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Measuring Vital Signs

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