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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. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Radial
120/80
ausculatation
Pulse

2. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Rhonchi
low
apnea
oximeter

3. Those at risk for hypothermia include
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.
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.
oximetry
Biot's respirations

4. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Korotkoff sounds Phase IV: Muffling
Conduction
Systolic pressure
absent

5. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
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
Acute anxiety stimulate the nervous system - raising the pulse.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

6. The difference between the systolic pressure and the diastolic pressure
Vascular resistance drops and the blood pressure decreases
Pulse pressure
^160/^100
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

7. 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
96.5 to 97.5
raises BP.
Pedal pulse
It will also fall

8. How does size affect pulse?
crackles
remittent
arrhythmia
Tall - slender people mayy ave a slower pulse rate than short - stout persons

9. How should baby's temperature be taken?
Axillary.
Irregular
Increases as body tries to remove excess heat
Systolic pressure

10. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Systolic pressure
shallow or slow breathing
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
hypoxia

11. 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.
about 1 degree lower than oral temperatures
Tachypnea
Korotkoff sounds Phase III: Knocking
Blood pressure increases because there is more volume of blood in the vascular system.

12. Abrupt decline in fever
dyspnea
Korotkoff sounds Phase V: Silence
Crisis
oximetry

13. Stress & emotions. BP?
higher
Relapsing
about 1 degree higher than oral temperatures
shallow or slow breathing

14. Full and bounding (even beats wit strong force)
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
+3
cardiac patients or patients who have had rectal surgery.
palpate

15. Stage 2 hypertension
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
^160/^100
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

16. The volume of blood pushed into the aorta per heartbeat.
Stroke volume
from drug therapy - a neurologic problem or dehydration.
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.
Sinoatrial node (SA NODE)

17. High BP
carotid
Pons and Medulla of the brainstem
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
hypertension

18. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
shallow or slow breathing
96.5 to 97.5
ausculatation
Stertor

19. Blood pressure for any adult should be no higher than
hypoxia
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
intermittent
120/80

20. Diurnal variation BP?
blood pressure is lowest in the morning. and higher in the afternoone
hypoxia
16-20
shallow or slow breathing

21. Whats the best position to take a rectal temperature?
16-20
Temperature will remain below 102 degrees with use of hypothermia blanket
Stertor
left Sims position

22. Slow and shallow breathing - leads to hypoxemia.
bradypnea
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.
higher
72 bpm

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

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24. Measurement of oxygen
oximetry
Brachial
3 in the right lung and 2 lobes in the left
Irregular

25. Rectal temperature are
about 1 degree higher than oral temperatures
Korotkoff sounds Phase II Swishing
+3
apnea

26. 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?
Crisis
Stroke volume
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Radial

27. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
raises BP.
the lungs
Crisis
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.

28. Absence of breathing
apnea
30-80
constant
uncooperative patient - children - combative patients - dementia

29. What happens to the blood if overhydration occurs?
Cardiac Output
Nursing interventions to reduce fever
Blood pressure increases because there is more volume of blood in the vascular system.
Temporal

30. 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
crackles
96.5 to 97.5
hypertension

31. How does external respiration occur?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
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
hypoxia
120-139/80-89

32. What happens when vasodilation occurs?
Brachial
The pulse rate gradually diminishes from birth to adulthood
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

33. 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
Core Temperature
Convection
the blood pressure will rise in order to push the blood along.

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

35. Louder knocking sound that occurs wit each heartbeat
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
higher
Tachypnea
Korotkoff sounds Phase III: Knocking

36. Feel
low
palpate
temperature - pulse - respiration - blood pressure - and pain level.
3 in the right lung and 2 lobes in the left

37. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
wheeze
Korotkoff sounds Phase II Swishing
Korotkoff sounds
intermittent

38. Sex BP?
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.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
absent
males have higher bp - until menopause then they are the same

39. No pulse palpable or heard on ausculation
absent
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.
carotid
Diastolic pressure

40. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
higher
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Pedal pulse
Evaporation

41. 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.
16-20
16-20
remittent
Increases as body tries to remove excess heat

42. Signs and symptoms of shock
Kussmaul's respiration
3 in the right lung and 2 lobes in the left
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Diastolic pressure

43. Side of neck
arrhythmia
Relapsing
carotid
hyperoxia

44. How should respirations be counted?
Evaporation
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
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
temperature - pulse - respiration - blood pressure - and pain level.

45. Low oxygen
lysis
hypoxia
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
It increases to push the blood through more rigid pathways.

46. The maximum pressure exerted on the artery during left ventricular contraction.
males have higher bp - until menopause then they are the same
Core Temperature
shallow or slow breathing
Systolic pressure

47. Head injury BP?
carotid
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.
raises BP.
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.

48. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
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
72 bpm
shallow or slow breathing
stridor

49. When should rectal temperatures NOT be used?
constant
Blood pressure increases because there is more volume of blood in the vascular system.
cardiac patients or patients who have had rectal surgery.
tachycardia

50. How does age affect pulse?
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.
The pulse rate gradually diminishes from birth to adulthood
Temperature will remain below 102 degrees with use of hypothermia blanket

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Measuring Vital Signs

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