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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. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
bradypnea
Pedal pulse
the blood pressure will rise in order to push the blood along.
Pulse pressure

2. 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
Hyperventilation
hypoxemia
blood pressure is lowest in the morning. and higher in the afternoone
Biot's respirations

3. Murmur or swishing sounds that increase as the cuff is deflated
Stertor
bradycardia
Korotkoff sounds Phase II Swishing
Diaphoresis

4. 1st stage of fever is?
ausculatation
hypoxia
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
shallow or slow breathing

5. How do you measure the apical pulse?
Evaporation
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
+3
Apical

6. The average temperature in the older adult
96.5 to 97.5
dyspnea
Rhonchi
Korotkoff sounds Phase II Swishing

7. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
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.
Femoral

8. Adolescent
16-20
bradypnea
in the alveoli - tiny thin-walled sacs
Stroke Volume

9. Slow and shallow breathing - leads to hypoxemia.
hypoxemia
higher
Systolic pressure
bradypnea

10. Newborn
30-80
Posterior tibial
the blood pressure will rise in order to push the blood along.
the lungs

11. The temperature of the deep tissues of the body
Core Temperature
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
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
96.5 to 97.5

12. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
It increases to push the blood through more rigid pathways.
higher
Stroke Volume
apnea

13. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
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
pyrogens
Core Temperature

14. Feel
palpate
120-139/80-89
in the alveoli - tiny thin-walled sacs
stridor

15. If the cardiac output falls what will happen to the BP?
It will also fall
Sinoatrial node (SA NODE)
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
hypoxemia

16. No pulse palpable or heard on ausculation
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
The pulse rate gradually diminishes from birth to adulthood
Respiration
absent

17. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
16-20
about 1 degree lower than oral temperatures
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Respiration

18. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
Hyperthermia related to infection or excessive heat exposure
120/80
stridor

19. 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
16-20
Pedal pulse
carotid
Increases as body tries to remove excess heat

20. Lobes in the lungs?
Stertor
3 in the right lung and 2 lobes in the left
shallow or slow breathing
97.5 to 99.5

21. 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?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Apical

22. Elevated temperature
16-20
fever
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.
blood pressure is lowest in the morning. and higher in the afternoone

23. What affects does aging do to the respiratory rate?
the lungs
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
shallow or slow breathing
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

24. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
Nursing interventions to reduce fever
low
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

25. Disappearance of sound. (marks diastolic pressure in adults)
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Korotkoff sounds Phase V: Silence
Temperature will remain below 102 degrees with use of hypothermia blanket
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

26. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
arrhythmia
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
bradypnea
Cheyenne-Stokes

27. Does the respiration rate increase or decrease during fever?
Increases as body tries to remove excess heat
Systolic pressure
Nursing interventions to reduce 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

28. 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
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Nursing interventions to reduce fever
120/70
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

29. When is apicial pulse used?
hypoxia
stridor
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.
Core Temperature

30. Are infants blood pressure low or high?
20-30
low
Core Temperature
Evaporation

31. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Axillary.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Conduction
Korotkoff sounds Phase IV: Muffling

32. Fever above 100.2 F
pyrexia
+1
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.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

33. Average blood pressure should be
ausculatation
120/70
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.
low BP

34. Full and bounding (even beats wit strong force)
+3
intermittent
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.
Femoral

35. How is shock caused?
oximeter
higher
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
arrhythmia

36. Louder knocking sound that occurs wit each heartbeat
Brachial
Korotkoff sounds Phase III: Knocking
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
The emotions increase hormone secretion - and the body activities required for this increase heat production.

37. How do drugs affect pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
12-20
temperature - pulse - respiration - blood pressure - and pain level.
oximeter

38. Breathing is an involuntary automatic function controlled by the respiratory center located where?
ausculatation
Pons and Medulla of the brainstem
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Femoral

39. What should you do if you cannot determine BP by ausculation?
Relapsing
Respiration
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.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

40. Stage 2 hypertension
^160/^100
stridor
120/80
Femoral

41. Both strong and weak beats occur within 1 minute
hypoxemia
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.
Temperature will remain below 102 degrees with use of hypothermia blanket
Irregular

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

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43. Those at risk for hypothermia include
Korotkoff sounds
The emotions increase hormone secretion - and the body activities required for this increase heat production.
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.
Feeble

44. How does external respiration occur?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
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
Cardiac Output
Increases as body tries to remove excess heat

45. 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.
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.
Hypothermia
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
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

46. This affects the character of the pulse.
Tachypnea
Dorsalis pedis
lysis
Stroke Volume

47. Blood pressure for any adult should be no higher than
low
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
Temperature will remain below 102 degrees with use of hypothermia blanket
120/80

48. Rectal temperature are
about 1 degree higher than oral temperatures
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
men - African Americans - under a lot of stress - obese
Hypothermia

49. Drop in blood pressure when arising to a standing position.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Stertor
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
orthostatic hypertension

50. The volume of blood pushed into the aorta per heartbeat.
stridor
blood pressure is lowest in the morning. and higher in the afternoone
Stroke volume
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

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Measuring Vital Signs

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