Measuring Vital Signs

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• 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. Top of left foot
Diaphoresis
Korotkoff sounds Phase III: Knocking
Dorsalis pedis
remittent


2. Fast - deep respirations with abrupt pauses

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3. A normal - relaxed breathing pattern
16-20
Eupnea
Diastolic pressure
Korotkoff sounds Phase II Swishing


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

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5. Whats the best position to take a rectal temperature?
left Sims position
Core Temperature
Korotkoff sounds Phase IV: Muffling
oximeter


6. Gradual return to a normal temperature
+3
Increases as body tries to remove excess heat
lysis
remittent


7. How do you measure the apical pulse?
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.
It increases to push the blood through more rigid pathways.
Brachial
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


8. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Respiration
The pulse rate gradually diminishes from birth to adulthood
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
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.


9. How does disease increase the body's temperature?
It will also fall
Korotkoff sounds
Crisis
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.


10. How should baby's temperature be taken?
Axillary.
Pedal pulse
Acute anxiety stimulate the nervous system - raising the pulse.
3 in the right lung and 2 lobes in the left


11. Stress & emotions. BP?
higher
Stertor
about 1 degree lower than oral temperatures
It increases to push the blood through more rigid pathways.


12. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
The pulse rate gradually diminishes from birth to adulthood
remittent
Evaporation
Korotkoff sounds


13. When should rectal temperatures be used?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
BMR
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
Diastolic pressure


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

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

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16. 2nd stage of fever is?
120/70
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
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
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.


17. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Korotkoff sounds Phase II Swishing
Stertor
12-20
Hyperthermia related to infection or excessive heat exposure


18. What happens to the blood if overhydration occurs?
Blood pressure increases because there is more volume of blood in the vascular system.
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.
Eupnea
thready


19. If the cardiac output falls what will happen to the BP?
It will also fall
Dorsalis pedis
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
uncooperative patient - children - combative patients - dementia


20. People most at risk for hypertension
Acute anxiety stimulate the nervous system - raising the pulse.
men - African Americans - under a lot of stress - obese
Vascular resistance drops and the blood pressure decreases
+1


21. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
palpate
16-20
orthostatic hypertension
low BP


22. The maximum pressure exerted on the artery during left ventricular contraction.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
BMR
Stroke volume
Systolic pressure


23. Those at risk for hypothermia include
Temperature will remain below 102 degrees with use of hypothermia blanket
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
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


24. 3 yr old
20-30
males have higher bp - until menopause then they are the same
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
raises BP.


25. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Cheyenne-Stokes
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Tachypnea
systolic pressure indicated by faint - clear sound that gradually grow louder.


26. An example of a nursing diagnoses
72 bpm
hypoxemia
Posterior tibial
Hyperthermia related to infection or excessive heat exposure


27. No pulse palpable or heard on ausculation
absent
constant
60 to 70 mL
The pulse rate gradually diminishes from birth to adulthood


28. Average pulse rate for an adult
about 1 degree lower than oral temperatures
wheeze
Temperature will remain below 102 degrees with use of hypothermia blanket
72 bpm


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

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30. The average temperature in the older adult
96.5 to 97.5
Increases as body tries to remove excess heat
uncooperative patient - children - combative patients - dementia
Korotkoff sounds Phase IV: Muffling


31. Average blood pressure should be
oximetry
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
120/70
temperature - pulse - respiration - blood pressure - and pain level.


32. Pulse above 100 beats per minute
tachycardia
carotid
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
+1


33. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Korotkoff sounds Phase II Swishing
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.
Pulse
hypotension


34. Are infants blood pressure low or high?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
remittent
low
Korotkoff sounds Phase III: Knocking


35. Both strong and weak beats occur within 1 minute
wheeze
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
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
Irregular


36. 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
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
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
remittent


37. Groin area
Pedal pulse
hypoxemia
Femoral
intermittent


38. Bend of knee
Posterior tibial
oximeter
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
popliteal


39. How does emotional stress raise the body's temperature?
Stroke volume
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Apical
16-20


40. Absence of breathing
120-139/80-89
apnea
Tachypnea
the rate - the rhythm - and volume


41. What affects does aging do to the respiratory rate?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
oximeter
Cardiac Output


42. The difference between the systolic pressure and the diastolic pressure
60 to 70 mL
Pulse pressure
orthostatic hypertension
Crisis


43. 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
Stroke volume
120/70
20-30


44. Abrupt decline in fever
Systolic pressure
constant
Crisis
Korotkoff sounds Phase II Swishing


45. High BP
72 bpm
tachycardia
hypertension
Systolic pressure


46. Disappearance of sound. (marks diastolic pressure in adults)
hyperoxia
Korotkoff sounds Phase IV: Muffling
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
Korotkoff sounds Phase V: Silence


47. BP at or lower 90/60.
Tachypnea
Stroke Volume
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
hypotension


48. Rectal temperature are
hypoxia
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
about 1 degree higher than oral temperatures
uncooperative patient - children - combative patients - dementia


49. Air movemtn causes heat to be transferred from the skin to the air molecules.
Radial
pyrexia
crackles
Convection


50. Diurnal variation BP?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
blood pressure is lowest in the morning. and higher in the afternoone
Femoral
Blood pressure increases because there is more volume of blood in the vascular system.