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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
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. 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
thready
shallow or slow breathing
Nursing interventions to reduce fever
Diastolic 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
16-20
pyrogens
Korotkoff sounds Phase IV: Muffling

3. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Stroke Volume
^160/^100
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

4. BP at or lower 90/60.
bradypnea
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.
low BP
hypotension

5. Taking a rectal temperature
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Nursing interventions to reduce fever
The pulse rate gradually diminishes from birth to adulthood
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

6. Korotkoff sounds Ausculatatory gap:
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Evaporation
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
hypoxia

7. Weak and regular (even beats wit poor force)
+1
oximeter
20-30
about 1 degree higher than oral temperatures

8. Does the respiration rate increase or decrease during fever?
16-20
Increases as body tries to remove excess heat
96.5 to 97.5
Sinoatrial node (SA NODE)

9. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Pulse pressure
30-80
from drug therapy - a neurologic problem or dehydration.
shallow or slow breathing

10. 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
hypoxemia
Korotkoff sounds Phase IV: Muffling
Temporal

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

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12. How is shock caused?
+1
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
the rate - the rhythm - and volume
oximeter

13. How does external respiration occur?
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
dyspnea
intermittent
Irregular

14. Stage 1 hypertension
Hypothermia
thready
Pulse
140-159/90-99

15. Louder knocking sound that occurs wit each heartbeat
Korotkoff sounds Phase III: Knocking
Temporal
low BP
hypertension

16. Elderly respiration
Pedal pulse
16-20
hypertension
Conduction

17. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Cheyenne-Stokes
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
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

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

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19. Low oxygen
dyspnea
constant
Biot's
hypoxia

20. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
The pulse rate gradually diminishes from birth to adulthood
Korotkoff sounds Phase IV: Muffling
20-30
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.

21. Normal body temperature ranges?
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.
It will also fall
+2
97.5 to 99.5

22. Groin area
97.5 to 99.5
thready
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
Femoral

23. Drop in blood pressure when arising to a standing position.
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
Femoral
thready
orthostatic hypertension

24. The average temperature in the older adult
Pulse
Apical
96.5 to 97.5
120/70

25. By measuring the blood pressure you obtain vital info about what?
Korotkoff sounds
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
Hypothermia
popliteal

26. Absence of breathing
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
apnea
16-20
Femoral

27. When should rectal temperatures NOT 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.
arrhythmia
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
cardiac patients or patients who have had rectal surgery.

28. 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.
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
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

29. Symptoms of hypoxia
palpate
systolic pressure indicated by faint - clear sound that gradually grow louder.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
30-80

30. Gradual return to a normal temperature
lysis
Vascular resistance drops and the blood pressure decreases
Temperature will remain below 102 degrees with use of hypothermia blanket
Nursing interventions to reduce fever

31. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
the rate - the rhythm - and volume
Feeble
constant
Pulse

32. Why would patients experience orthostatic hypotenstion?
absent
Evaporation
Conduction
from drug therapy - a neurologic problem or dehydration.

33. How does age affect pulse?
The pulse rate gradually diminishes from birth to adulthood
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
hyperoxia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

34. Feel
Posterior tibial
140-159/90-99
palpate
Femoral

35. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
hypertension
cardiac patients or patients who have had rectal surgery.
stridor
palpate

36. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
low BP
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
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.
ausculatation

37. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
in the alveoli - tiny thin-walled sacs
96.5 to 97.5
Evaporation
wheeze

38. Air movemtn causes heat to be transferred from the skin to the air molecules.
arrhythmia
wheeze
Convection
Respiration

39. How do you measure the apical pulse?
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
Stertor
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

40. Korotkoff sounds Phase I: Tapping
Tachypnea
Eupnea
Acute anxiety stimulate the nervous system - raising the pulse.
systolic pressure indicated by faint - clear sound that gradually grow louder.

41. Pulse lower than 60 beats per minute
arrhythmia
120/80
Diastolic pressure
bradycardia

42. Fast - deep respirations with abrupt pauses

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43. How does increased body temperature increase the pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Korotkoff sounds Phase V: Silence
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
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

44. 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.
remittent
Tachypnea
Eupnea
oximetry

45. Fever above 100.2 F
popliteal
Hyperthermia related to infection or excessive heat exposure
cardiac patients or patients who have had rectal surgery.
pyrexia

46. Decreased levels of oxygen in the blood - often seen in patients wo are under medical sedation - who are recovering from anesthesia or abdominal surgery - or who are in a weak or debiliated condition.
140-159/90-99
Blood pressure increases because there is more volume of blood in the vascular system.
crackles
hypoxemia

47. Those at risk for hypothermia include
bradycardia
It increases to push the blood through more rigid pathways.
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.
raises BP.

48. High BP
Radial
hypertension
Stroke Volume
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

49. Enviromental temperature BP?
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
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.
wheeze
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

50. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
Diastolic pressure
hypoxia
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.