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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. Average pulse rate for an adult
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.
BMR
72 bpm
Sinoatrial node (SA NODE)

2. 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?
Brachial
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.
Hypothermia
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

3. Diurnal variation 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
blood pressure is lowest in the morning. and higher in the afternoone
bradycardia
Sinoatrial node (SA NODE)

4. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
oximeter
97.5 to 99.5
low BP
12-20

5. Louder knocking sound that occurs wit each heartbeat
Radial
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Korotkoff sounds Phase III: Knocking
Posterior tibial

6. Taking a rectal temperature
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.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Biot's respirations
BMR

7. Measurement of oxygen
hyperoxia
oximetry
Vascular resistance drops and the blood pressure decreases
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.

8. Pulse above 100 beats per minute
Posterior tibial
tachycardia
Hyperthermia related to infection or excessive heat exposure
Temperature will remain below 102 degrees with use of hypothermia blanket

9. Barely palpable
Cardiac Output
Feeble
from drug therapy - a neurologic problem or dehydration.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

10. Side of wrist
Radial
hypoxia
Korotkoff sounds Phase II Swishing
the rate - the rhythm - and volume

11. Weak and may be irregular
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.
thready
from drug therapy - a neurologic problem or dehydration.
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.

12. Absence of breathing
low
stridor
120/80
apnea

13. Weak and regular (even beats wit poor force)
Respiration
+1
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Pedal pulse

14. The average temperature in the older adult
Korotkoff sounds Phase V: Silence
Posterior tibial
systolic pressure indicated by faint - clear sound that gradually grow louder.
96.5 to 97.5

15. Healthly adult
12-20
Nursing interventions to reduce fever
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
It will also fall

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

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17. When should rectal temperatures NOT be used?
+1
cardiac patients or patients who have had rectal surgery.
hypoxia
Tall - slender people mayy ave a slower pulse rate than short - stout persons

18. What affects does aging do to the respiratory rate?
Blood pressure increases because there is more volume of blood in the vascular system.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

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

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20. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
+1
Diastolic pressure
Blood pressure increases because there is more volume of blood in the vascular system.
Dorsalis pedis

21. 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.
Radial
Tachypnea
about 1 degree lower than oral temperatures
Korotkoff sounds Phase IV: Muffling

22. Top of left foot
Hyperthermia related to infection or excessive heat exposure
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.
Convection
Dorsalis pedis

23. Fever above 100.2 F
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.
pyrexia
palpate
60 to 70 mL

24. Air movemtn causes heat to be transferred from the skin to the air molecules.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
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
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.

25. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Korotkoff sounds Phase II Swishing
Sinoatrial node (SA NODE)
Diaphoresis
Respiration

26. Those at risk for hypothermia include
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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.
dyspnea

27. Inside ankle
hypoxemia
16-20
Hypothermia
Posterior tibial

28. The volume of blood pushed into the aorta per heartbeat.
12-20
low
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Stroke volume

29. 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.
Hyperventilation
Sinoatrial node (SA NODE)
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

30. Rectal temperature are
about 1 degree higher than oral temperatures
cardiac patients or patients who have had rectal surgery.
bradycardia
Vascular resistance drops and the blood pressure decreases

31. Stage 2 hypertension
Pedal pulse
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.
^160/^100
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

32. What characteristics should be noted when checking the pulse?
Cardiac Output
the rate - the rhythm - and volume
bradycardia
It increases to push the blood through more rigid pathways.

33. How does emotional stress raise the body's temperature?
arrhythmia
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Increases as body tries to remove excess heat

34. Side of forehead
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
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.
Temporal
Kussmaul's respiration

35. How does disease increase the body's 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
arrhythmia
apnea
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

36. 3rd stage of fever?
Evaporation
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Diaphoresis
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

37. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
stridor
wheeze
Pedal pulse
apnea

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

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39. What affects does aging do to the blood pressure?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Evaporation
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
the rate - the rhythm - and volume

40. How cardiac contractions are normally initiated by the electrical impules emerging from what?
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.
popliteal
uncooperative patient - children - combative patients - dementia
Sinoatrial node (SA NODE)

41. Bend of knee
Korotkoff sounds Phase II Swishing
ausculatation
popliteal
men - African Americans - under a lot of stress - obese

42. Heart
Apical
3 in the right lung and 2 lobes in the left
Feeble
Temperature will remain below 102 degrees with use of hypothermia blanket

43. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
lysis
It increases to push the blood through more rigid pathways.
constant
palpate

44. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
in the alveoli - tiny thin-walled sacs
Korotkoff sounds Phase II Swishing
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.
Kussmaul's respiration

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

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46. When should rectal temperatures be used?
Vascular resistance drops and the blood pressure decreases
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
140-159/90-99
Biot's respirations

47. How does physical exercise raise the body's temperature?
20-30
It will also fall
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.
systolic pressure indicated by faint - clear sound that gradually grow louder.

48. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
the blood pressure will rise in order to push the blood along.
Kussmaul's respiration
constant
Korotkoff sounds Phase V: Silence

49. Gas exchange in the blood occurs where?
Increases as body tries to remove excess heat
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
in the alveoli - tiny thin-walled sacs
Hypothermia

50. High BP
hypertension
3 in the right lung and 2 lobes in the left
low BP
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.

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Measuring Vital Signs

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