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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.
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. How is shock caused?
30-80
intermittent
16-20
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

2. Taking axillary temperature
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.
wheeze
Biot's
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

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

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4. A normal - relaxed breathing pattern
about 1 degree higher than oral temperatures
Rhonchi
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Eupnea

5. When should rectal temperatures be used?
Korotkoff sounds Phase II Swishing
12-20
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
Biot's

6. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
palpate
arrhythmia
Core Temperature
men - African Americans - under a lot of stress - obese

7. How does menstrual cycle and pregnancy raise the body's temperature?
+3
stridor
Pulse pressure
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

8. What are the 5 vital signs?
lysis
temperature - pulse - respiration - blood pressure - and pain level.
20-30
Femoral

9. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Femoral
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.
Sinoatrial node (SA NODE)

10. Both strong and weak beats occur within 1 minute
Irregular
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Stertor
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

11. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Diastolic pressure
higher
Stertor
Conduction

12. Measurement of oxygen
raises BP.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Tachypnea
oximetry

13. Average pulse rate for an adult
hyperoxia
Radial
ausculatation
72 bpm

14. 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?
males have higher bp - until menopause then they are the same
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
the blood pressure will rise in order to push the blood along.
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.

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

16. How does emotional stress raise the body's temperature?
systolic pressure indicated by faint - clear sound that gradually grow louder.
the blood pressure will rise in order to push the blood along.
low
The emotions increase hormone secretion - and the body activities required for this increase heat production.

17. Stress & emotions. BP?
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
higher
Respiration

18. How do you measure the apical pulse?
pyrexia
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
popliteal
The pulse rate gradually diminishes from birth to adulthood

19. Groin area
Femoral
temperature - pulse - respiration - blood pressure - and pain level.
bradypnea
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

20. High BP
hypertension
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
wheeze
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

21. 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
dyspnea
Stroke Volume
Hyperventilation
thready

22. Alternating rise and fall of the temperature.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
intermittent
hypoxia
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

23. Korotkoff sounds Ausculatatory gap:
Pulse
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Evaporation

24. BP at or lower 90/60.
hypotension
males have higher bp - until menopause then they are the same
Temporal
the blood pressure will rise in order to push the blood along.

25. 2nd stage of fever is?
Stertor
72 bpm
Pons and Medulla of the brainstem
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.

26. Enviromental temperature BP?
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.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Korotkoff sounds Phase III: Knocking
Systolic pressure

27. How should respirations be counted?
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.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
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.

28. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
left Sims position
Posterior tibial
Korotkoff sounds
Biot's

29. The average temperature in the older adult
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.
96.5 to 97.5
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Nursing interventions to reduce fever

30. Absence of breathing
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
shallow or slow breathing
apnea
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.

31. How does increased body temperature increase the pulse?
^160/^100
Pons and Medulla of the brainstem
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

32. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
the blood pressure will rise in order to push the blood along.
hypertension
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

33. Top of left foot
apnea
Dorsalis pedis
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.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

34. Murmur or swishing sounds that increase as the cuff is deflated
popliteal
Crisis
30-80
Korotkoff sounds Phase II Swishing

35. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
carotid
remittent
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.
30-80

36. Side of forehead
12-20
orthostatic hypertension
Radial
Temporal

37. 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.
about 1 degree higher than oral temperatures
low BP
remittent
+1

38. Does the respiration rate increase or decrease during fever?
Pons and Medulla of the brainstem
Increases as body tries to remove excess heat
males have higher bp - until menopause then they are the same
the rate - the rhythm - and volume

39. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Cheyenne-Stokes
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Eupnea
Radial

40. When warm skin touches a cool object - heat is lost to the object.
Conduction
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Kussmaul's respiration
systolic pressure indicated by faint - clear sound that gradually grow louder.

41. Rectal temperature are
Core Temperature
12-20
about 1 degree higher than oral temperatures
Pulse

42. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
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.
30-80
Pulse
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

43. How do emotions increase the pulse rate?
Acute anxiety stimulate the nervous system - raising the pulse.
crackles
Tachypnea
Korotkoff sounds Phase II Swishing

44. The temperature of the deep tissues of the body
Relapsing
Core Temperature
Vascular resistance drops and the blood pressure decreases
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

45. Substances tat cause fever
Crisis
pyrogens
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
BMR

46. Diurnal variation BP?
from drug therapy - a neurologic problem or dehydration.
hyperoxia
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
blood pressure is lowest in the morning. and higher in the afternoone

47. Drop in blood pressure when arising to a standing position.
orthostatic hypertension
Pons and Medulla of the brainstem
Diastolic pressure
temperature - pulse - respiration - blood pressure - and pain level.

48. Strong and regular ( even beats wit moderate force)
Diaphoresis
Conduction
+2
20-30

49. How does physical exercise raise the body's temperature?
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.
the rate - the rhythm - and volume
The pulse rate gradually diminishes from birth to adulthood

50. Inside ankle
120/80
about 1 degree lower than oral temperatures
Posterior tibial
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.