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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. When should rectal temperatures be used?
Biot's
Cheyenne-Stokes
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
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

2. When warm skin touches a cool object - heat is lost to the object.
Conduction
Nursing interventions to reduce fever
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
20-30

3. How does external respiration occur?
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.
Respiration
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
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

4. State of insufficient oxygen
orthostatic hypertension
blood pressure is lowest in the morning. and higher in the afternoone
hypoxia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

5. Fever above 100.2 F
pyrexia
+1
Apical
Stroke Volume

6. An example of a nursing diagnoses
Systolic pressure
low BP
Acute anxiety stimulate the nervous system - raising the pulse.
Hyperthermia related to infection or excessive heat exposure

7. Korotkoff sounds Phase I: Tapping
hypoxemia
systolic pressure indicated by faint - clear sound that gradually grow louder.
97.5 to 99.5
Diastolic pressure

8. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
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
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Korotkoff sounds Phase IV: Muffling

9. When should rectal temperatures NOT be used?
Kussmaul's respiration
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
cardiac patients or patients who have had rectal surgery.
Pulse pressure

10. 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
the lungs
Conduction
Hyperthermia related to infection or excessive heat exposure

11. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Sinoatrial node (SA NODE)
Nursing interventions to reduce fever
72 bpm
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

12. Measurement of oxygen
Temperature will remain below 102 degrees with use of hypothermia blanket
oximetry
Acute anxiety stimulate the nervous system - raising the pulse.
fever

13. Signs and symptoms of shock
hypertension
Vascular resistance drops and the blood pressure decreases
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
^160/^100

14. Heart
It will also fall
Apical
popliteal
in the alveoli - tiny thin-walled sacs

15. Full and bounding (even beats wit strong force)
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.
Radial
+3
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

16. Are infants blood pressure low or high?
low
Korotkoff sounds Phase II Swishing
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

17. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
Posterior tibial
crackles
Hypothermia
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

18. 2nd stage of fever is?
Korotkoff sounds Phase II Swishing
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.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
hyperoxia

19. Side of wrist
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
120-139/80-89
Radial
oximetry

20. 1st stage of fever is?
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.
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
Diastolic pressure
wheeze

21. 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.
Diastolic pressure
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.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
crackles

22. Fast - deep respirations with abrupt pauses

23. 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
120-139/80-89
+2
shallow or slow breathing
Pedal pulse

24. 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
3 in the right lung and 2 lobes in the left
Nursing interventions to reduce fever
Tachypnea
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

25. Side of forehead
bradycardia
hypoxemia
Temporal
Stroke Volume

26. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
oximetry
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Temperature will remain below 102 degrees with use of hypothermia blanket
oximeter

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

28. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Sinoatrial node (SA NODE)
+1
Convection
Pons and Medulla of the brainstem

29. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Diaphoresis
Rhonchi
Irregular
Hyperventilation

30. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
popliteal
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
wheeze
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.

31. Lobes in the lungs?
Crisis
3 in the right lung and 2 lobes in the left
Pulse pressure
Biot's respirations

32. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
96.5 to 97.5
Blood pressure increases because there is more volume of blood in the vascular system.
hypoxia
the blood pressure will rise in order to push the blood along.

33. Taking axillary temperature
Korotkoff sounds Phase V: Silence
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
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.
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.

34. How should baby's temperature be taken?
Axillary.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
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.
Brachial

35. BP at or lower 90/60.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
hypoxemia
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
hypotension

36. 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
Pulse
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.
thready

37. 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?
16-20
systolic pressure indicated by faint - clear sound that gradually grow louder.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Tall - slender people mayy ave a slower pulse rate than short - stout persons

38. Absence of breathing
BMR
72 bpm
carotid
apnea

39. The temperature of the deep tissues of the body
Core Temperature
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
fever
bradycardia

40. How do drugs affect pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
systolic pressure indicated by faint - clear sound that gradually grow louder.
^160/^100
12-20

41. Rectal temperature are
Pons and Medulla of the brainstem
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
20-30
about 1 degree higher than oral temperatures

42. No pulse palpable or heard on ausculation
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
absent
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

43. Bend of knee
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.
+3
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
popliteal

44. The difference between the systolic pressure and the diastolic pressure
thready
Temperature will remain below 102 degrees with use of hypothermia blanket
Pulse pressure
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

45. Symptoms of hypoxia
the lungs
tachycardia
apnea
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

46. Top of left foot
Convection
Dorsalis pedis
orthostatic hypertension
dyspnea

47. Risk for prolonged hypertension
Conduction
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
The pulse rate gradually diminishes from birth to adulthood
Korotkoff sounds Phase V: Silence

48. Both strong and weak beats occur within 1 minute
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
males have higher bp - until menopause then they are the same
about 1 degree lower than oral temperatures
Irregular

49. What characteristics should be noted when checking the pulse?
Irregular
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
the rate - the rhythm - and volume
arrhythmia

50. Elderly respiration
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
Kussmaul's respiration
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.
16-20