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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. 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.
shallow or slow breathing
30-80
hypertension

2. Slow and shallow breathing - leads to hypoxemia.
shallow or slow breathing
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
120-139/80-89
bradypnea

3. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
BMR
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.
Tachypnea
constant

4. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
arrhythmia
shallow or slow breathing
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
the lungs

5. Normal body temperature ranges?
Eupnea
97.5 to 99.5
men - African Americans - under a lot of stress - obese
Femoral

6. The average temperature in the older adult
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
96.5 to 97.5
temperature - pulse - respiration - blood pressure - and pain level.
palpate

7. 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.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Stertor
crackles

8. By measuring the blood pressure you obtain vital info about what?
carotid
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
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
low BP

9. Air movemtn causes heat to be transferred from the skin to the air molecules.
hypotension
Convection
thready
20-30

10. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Brachial
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
oximeter

11. Hearing
ausculatation
Temperature will remain below 102 degrees with use of hypothermia blanket
Rhonchi
Stertor

12. When should rectal temperatures be used?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Kussmaul's respiration
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
Convection

13. Lobes in the lungs?
males have higher bp - until menopause then they are the same
3 in the right lung and 2 lobes in the left
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
120/80

14. Fever above 100.2 F
Hyperthermia related to infection or excessive heat exposure
16-20
It increases to push the blood through more rigid pathways.
pyrexia

15. Increased or rapid breathing results from te presence of fever and a number or diseases. breathing rate increased about 4 breaths for each degree increase in temperature.
constant
Tachypnea
males have higher bp - until menopause then they are the same
oximetry

16. Diurnal variation BP?
Irregular
140-159/90-99
blood pressure is lowest in the morning. and higher in the afternoone
pyrexia

17. 1st stage of fever is?
Korotkoff sounds Phase V: Silence
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
apnea
bradypnea

18. Alternating rise and fall of the temperature.
Nursing interventions to reduce fever
intermittent
120-139/80-89
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

19. Axillary temperature are
It increases to push the blood through more rigid pathways.
Blood pressure increases because there is more volume of blood in the vascular system.
about 1 degree lower than oral temperatures
Hyperthermia related to infection or excessive heat exposure

20. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
Nursing interventions to reduce fever
the lungs
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.
hypoxia

21. Fast - deep respirations with abrupt pauses

22. Are infants blood pressure low or high?
Crisis
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
low
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

23. Risk for prolonged hypertension
uncooperative patient - children - combative patients - dementia
97.5 to 99.5
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Diaphoresis

24. An example of a nursing diagnoses
hypoxemia
Hyperthermia related to infection or excessive heat exposure
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.
Rhonchi

25. Full and bounding (even beats wit strong force)
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
popliteal
+3
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

26. Elevated temperature
fever
uncooperative patient - children - combative patients - dementia
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

27. Whats the best position to take a rectal temperature?
left Sims position
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
hypertension
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.

28. Head injury BP?
Biot's
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
raises BP.

29. Abrupt decline in fever
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Crisis
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

30. Does the respiration rate increase or decrease during fever?
The pulse rate gradually diminishes from birth to adulthood
12-20
Increases as body tries to remove excess heat
palpate

31. The difference between the systolic pressure and the diastolic pressure
Conduction
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Pulse pressure
temperature - pulse - respiration - blood pressure - and pain level.

32. No pulse palpable or heard on ausculation
absent
uncooperative patient - children - combative patients - dementia
intermittent
BMR

33. How does menstrual cycle and pregnancy raise the body's temperature?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Biot's respirations
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
carotid

34. Newborn
Korotkoff sounds
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
30-80
temperature - pulse - respiration - blood pressure - and pain level.

35. 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.
Hypothermia
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.
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
+1

36. When the heart contracts How many mLs of blood is propelled into the aorta?
120-139/80-89
absent
Pedal pulse
60 to 70 mL

37. When warm skin touches a cool object - heat is lost to the object.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Conduction
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
systolic pressure indicated by faint - clear sound that gradually grow louder.

38. Pulse above 100 beats per minute
Axillary.
fever
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
tachycardia

39. Murmur or swishing sounds that increase as the cuff is deflated
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.
Korotkoff sounds Phase IV: Muffling
Sinoatrial node (SA NODE)
Korotkoff sounds Phase II Swishing

40. 3 yr old
ausculatation
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Evaporation
20-30

41. Excessive sweat production
Diaphoresis
^160/^100
about 1 degree higher than oral temperatures
hypotension

42. How do drugs affect pulse?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
+3
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

43. Drop in blood pressure when arising to a standing position.
Korotkoff sounds Phase V: Silence
carotid
dyspnea
orthostatic hypertension

44. Low oxygen
hypoxia
oximeter
140-159/90-99
+1

45. Feel
palpate
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Pulse
intermittent

46. How does size affect pulse?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
+1
fever
BMR

47. This affects the character of the pulse.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Stroke Volume
Biot's
Acute anxiety stimulate the nervous system - raising the pulse.

48. Obtaining the correct size for a cuff for BP?
uncooperative patient - children - combative patients - dementia
constant
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Stertor

49. Side of wrist
Radial
oximeter
BMR
Posterior tibial

50. Side of neck
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
popliteal
carotid
Increases as body tries to remove excess heat