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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. Adolescent
97.5 to 99.5
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Sinoatrial node (SA NODE)
16-20

2. What pulse is checked to determine whether there is any blockage of circulation in the artery up to that point - especially in patients who have had cardiac catherization using the femoral artery for the insertion of the catheter or those who had sur
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Pedal pulse
Evaporation

3. How do you measure the apical pulse?
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
Hyperthermia related to infection or excessive heat exposure
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
hypertension

4. Side of wrist
remittent
hypoxia
Radial
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

5. A normal - relaxed breathing pattern
Eupnea
+1
higher
Hypothermia

6. Blood pressure for any adult should be no higher than
Korotkoff sounds Phase III: Knocking
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
120/80
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

7. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Korotkoff sounds Phase II Swishing
Nursing interventions to reduce fever
Korotkoff sounds
72 bpm

8. Prehypertension
72 bpm
120-139/80-89
Korotkoff sounds Phase V: Silence
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

9. What should you do if you cannot determine BP by ausculation?
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.
Dorsalis pedis
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.
Stroke Volume

10. Substances tat cause fever
Korotkoff sounds Phase V: Silence
pyrogens
^160/^100
Nursing interventions to reduce fever

11. Excessive sweat production
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Diaphoresis
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.

12. Measurement of oxygen
120/70
The pulse rate gradually diminishes from birth to adulthood
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
oximetry

13. This affects the character of the pulse.
Evaporation
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.
Stroke Volume
16-20

14. Absence of breathing
intermittent
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
apnea
Irregular

15. The maximum pressure exerted on the artery during left ventricular contraction.
+1
temperature - pulse - respiration - blood pressure - and pain level.
Korotkoff sounds Phase III: Knocking
Systolic pressure

16. Fever above 100.2 F
pyrexia
remittent
shallow or slow breathing
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

17. Fast - deep respirations with abrupt pauses

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18. 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.
Pons and Medulla of the brainstem
16-20
remittent
dyspnea

19. Side of neck
Stroke Volume
Pedal pulse
tachycardia
carotid

20. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Diastolic pressure
+3
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Cheyenne-Stokes

21. How should respirations be counted?
Cardiac Output
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.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
raises BP.

22. Hearing
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
low
ausculatation
wheeze

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

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24. Why would patients experience orthostatic hypotenstion?
from drug therapy - a neurologic problem or dehydration.
97.5 to 99.5
tachycardia
Diastolic pressure

25. Whats the best position to take a rectal temperature?
left Sims position
popliteal
men - African Americans - under a lot of stress - obese
Kussmaul's respiration

26. Enviromental temperature BP?
+1
Diaphoresis
hyperoxia
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

27. Stage 1 hypertension
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Korotkoff sounds
140-159/90-99
oximeter

28. Stress & emotions. BP?
Systolic pressure
higher
hypotension
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

29. 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
The pulse rate gradually diminishes from birth to adulthood
16-20
Feeble
Hyperventilation

30. Diurnal variation BP?
constant
Pedal pulse
lysis
blood pressure is lowest in the morning. and higher in the afternoone

31. State of insufficient oxygen
hypoxia
16-20
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Pulse pressure

32. How does age affect pulse?
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.
The pulse rate gradually diminishes from birth to adulthood
Stroke volume
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

33. Elderly respiration
16-20
Sinoatrial node (SA NODE)
shallow or slow breathing
bradycardia

34. Risk for prolonged hypertension
orthostatic hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
males have higher bp - until menopause then they are the same
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

35. The average temperature in the older adult
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
96.5 to 97.5
intermittent

36. Abrupt decline in fever
+2
Radial
Crisis
systolic pressure indicated by faint - clear sound that gradually grow louder.

37. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
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
Rhonchi
Brachial
Pulse

38. BP at or lower 90/60.
hypotension
fever
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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.

39. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
constant
20-30
Diastolic pressure
hypoxia

40. 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
Biot's
Cheyenne-Stokes
lysis

41. An example of nursing planning
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
intermittent
Pulse pressure
Temperature will remain below 102 degrees with use of hypothermia blanket

42. Head injury BP?
raises BP.
Feeble
dyspnea
about 1 degree lower than oral temperatures

43. 3rd stage of fever?
120/80
Temperature will remain below 102 degrees with use of hypothermia blanket
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
60 to 70 mL

44. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
shallow or slow breathing
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.
Increases as body tries to remove excess heat
the lungs

45. People most at risk for hypertension
140-159/90-99
Increases as body tries to remove excess heat
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
men - African Americans - under a lot of stress - obese

46. 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.
Cardiac Output
Korotkoff sounds
the lungs
Respiration

47. By measuring the blood pressure you obtain vital info about what?
16-20
oximetry
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
popliteal

48. Taking axillary temperature
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.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
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.

49. Murmur or swishing sounds that increase as the cuff is deflated
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
hypoxia
Korotkoff sounds Phase II Swishing
remittent

50. How does emotional stress raise the body's temperature?
+1
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.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
+2