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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 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.
Irregular
systolic pressure indicated by faint - clear sound that gradually grow louder.
Evaporation

2. Disappearance of sound. (marks diastolic pressure in adults)
Pulse
Systolic pressure
Korotkoff sounds Phase V: Silence
orthostatic hypertension

3. Fever above 100.2 F
pyrexia
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
left Sims position
hyperoxia

4. Average pulse rate for an adult
Pulse
72 bpm
It will also fall
Relapsing

5. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
pyrogens
Posterior tibial
Cheyenne-Stokes
Korotkoff sounds Phase IV: Muffling

6. Heart
Apical
Sinoatrial node (SA NODE)
It will also fall
males have higher bp - until menopause then they are the same

7. Excessive sweat production
in the alveoli - tiny thin-walled sacs
60 to 70 mL
men - African Americans - under a lot of stress - obese
Diaphoresis

8. Side of wrist
Tachypnea
Radial
apnea
It will also fall

9. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
3 in the right lung and 2 lobes in the left
oximeter
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.
16-20

10. Weak and may be irregular
thready
120-139/80-89
Evaporation
Tall - slender people mayy ave a slower pulse rate than short - stout persons

11. Slow and shallow breathing - leads to hypoxemia.
bradypnea
16-20
Blood pressure increases because there is more volume of blood in the vascular system.
120-139/80-89

12. Whats the best position to take a rectal temperature?
left Sims position
hypotension
stridor
men - African Americans - under a lot of stress - obese

13. Enviromental temperature BP?
raises BP.
96.5 to 97.5
Apical
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

14. Stage 2 hypertension
Rhonchi
Cardiac Output
^160/^100
hyperoxia

15. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
blood pressure is lowest in the morning. and higher in the afternoone
pyrogens
arrhythmia
Irregular

16. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
dyspnea
Irregular
low BP

17. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
arrhythmia
tachycardia
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Evaporation

18. When warm skin touches a cool object - heat is lost to the object.
hyperoxia
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
systolic pressure indicated by faint - clear sound that gradually grow louder.
Conduction

19. Average blood pressure should be
16-20
Hyperthermia related to infection or excessive heat exposure
120/70
It increases to push the blood through more rigid pathways.

20. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
Acute anxiety stimulate the nervous system - raising the pulse.
oximeter
Increases as body tries to remove excess heat
Diastolic pressure

21. What characteristics should be noted when checking the pulse?
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 rate - the rhythm - and volume
Stroke Volume
absent

22. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
the blood pressure will rise in order to push the blood along.
low
Eupnea

23. The temperature falls to normal and then rises again in a repeating pattern.
Korotkoff sounds Phase II Swishing
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Relapsing

24. Gradual return to a normal temperature
lysis
dyspnea
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Evaporation

25. When is apicial pulse used?
30-80
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.
Temporal
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

26. An example of nursing planning
Temperature will remain below 102 degrees with use of hypothermia blanket
in the alveoli - tiny thin-walled sacs
30-80
pyrogens

27. 1st stage of fever is?
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
16-20
It increases to push the blood through more rigid pathways.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

28. How does external respiration occur?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
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
Posterior tibial

29. 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
120/80
ausculatation
Conduction

30. 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.
stridor
Posterior tibial
60 to 70 mL

31. High oxygen
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.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
hyperoxia
It increases to push the blood through more rigid pathways.

32. An example of a nursing diagnoses
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.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
It will also fall
Hyperthermia related to infection or excessive heat exposure

33. Why would patients experience orthostatic hypotenstion?
from drug therapy - a neurologic problem or dehydration.
Feeble
30-80
arrhythmia

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

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35. How does emotional stress raise the body's temperature?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Relapsing
Brachial
pyrogens

36. 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
tachycardia
3 in the right lung and 2 lobes in the left
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.
Hyperventilation

37. How does menstrual cycle and pregnancy raise the body's temperature?
120/70
Temperature will remain below 102 degrees with use of hypothermia blanket
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Respiration

38. Taking axillary temperature
60 to 70 mL
pyrexia
Korotkoff sounds Phase III: Knocking
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.

39. The maximum pressure exerted on the artery during left ventricular contraction.
Stertor
97.5 to 99.5
lysis
Systolic pressure

40. Rectal temperature are
Femoral
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
hypoxia
about 1 degree higher than oral temperatures

41. This affects the character of the pulse.
orthostatic hypertension
shallow or slow breathing
Stroke Volume
Relapsing

42. 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
Nursing interventions to reduce fever
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
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 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.

43. Signs and symptoms of shock
arrhythmia
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
BMR
Apical

44. Stress & emotions. BP?
hypoxemia
higher
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.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

45. Hearing
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Hypothermia
ausculatation
low

46. Strong and regular ( even beats wit moderate force)
+2
intermittent
constant
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

47. When the heart contracts How many mLs of blood is propelled into the aorta?
It will also fall
60 to 70 mL
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
bradycardia

48. How should respirations be counted?
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Acute anxiety stimulate the nervous system - raising the pulse.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Pons and Medulla of the brainstem

49. By measuring the blood pressure you obtain vital info about what?
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
Systolic pressure
3 in the right lung and 2 lobes in the left
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

50. What happens to the blood if overhydration occurs?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Blood pressure increases because there is more volume of blood in the vascular system.
popliteal
Dorsalis pedis