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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. Diurnal variation BP?
Relapsing
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Systolic pressure
blood pressure is lowest in the morning. and higher in the afternoone

2. Adolescent
systolic pressure indicated by faint - clear sound that gradually grow louder.
16-20
shallow or slow breathing
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.

3. 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
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
arrhythmia
constant
Nursing interventions to reduce fever

4. Hearing
Temperature will remain below 102 degrees with use of hypothermia blanket
ausculatation
It will also fall
Kussmaul's respiration

5. Average pulse rate for an adult
Respiration
Evaporation
72 bpm
crackles

6. No pulse palpable or heard on ausculation
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
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.
absent
Diastolic pressure

7. When is apicial pulse used?
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.
Apical
fever
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

8. Fast - deep respirations with abrupt pauses

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9. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
constant
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.
Convection
+3

10. Prehypertension
Diaphoresis
120-139/80-89
BMR
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

11. What affects does aging do to the respiratory rate?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
12-20
140-159/90-99
Systolic pressure

12. How does external respiration occur?
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
Korotkoff sounds Phase II Swishing
temperature - pulse - respiration - blood pressure - and pain level.
Increases as body tries to remove excess heat

13. Subnormal body temperature the regulating center in the hypothalamus is greatly impaired when the temperature of the body falls below 94 degrees - at that point? sleepiness and coma are apt to develop.
pyrexia
The pulse rate gradually diminishes from birth to adulthood
Hypothermia
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.

14. When the heart contracts How many mLs of blood is propelled into the aorta?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Apical
60 to 70 mL
Tachypnea

15. Are infants blood pressure low or high?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
low
tachycardia
left Sims position

16. 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.
arrhythmia
Systolic pressure
crackles
absent

17. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Pulse
Increases as body tries to remove excess heat
the blood pressure will rise in order to push the blood along.
about 1 degree higher than oral temperatures

18. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
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
Rhonchi
remittent
Tall - slender people mayy ave a slower pulse rate than short - stout persons

19. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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
shallow or slow breathing
Respiration

20. right arm vs. left arm/ arm vs. leg BP?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
bradycardia
The pulse rate gradually diminishes from birth to adulthood
Diastolic pressure

21. How does disease increase the body's temperature?
Apical
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
absent
Vascular resistance drops and the blood pressure decreases

22. Fever above 100.2 F
pyrexia
Convection
+3
the lungs

23. State of insufficient 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.
cardiac patients or patients who have had rectal surgery.
about 1 degree lower than oral temperatures
hypoxia

24. Weak and regular (even beats wit poor force)
+1
It increases to push the blood through more rigid pathways.
16-20
Convection

25. 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
Pulse
120/80
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

26. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
popliteal
the lungs
72 bpm
Temperature will remain below 102 degrees with use of hypothermia blanket

27. If the cardiac output falls what will happen to the BP?
oximetry
left Sims position
3 in the right lung and 2 lobes in the left
It will also fall

28. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Acute anxiety stimulate the nervous system - raising the pulse.
Pons and Medulla of the brainstem
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.
Feeble

29. High BP
hypertension
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.
about 1 degree lower than oral temperatures

30. What are the 5 vital signs?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
temperature - pulse - respiration - blood pressure - and pain level.
60 to 70 mL
Radial

31. Substances tat cause fever
Irregular
bradypnea
pyrogens
120/70

32. Those at risk for hypothermia include
+3
tachycardia
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
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.

33. Head injury BP?
Korotkoff sounds Phase V: Silence
stridor
raises BP.
Korotkoff sounds Phase IV: Muffling

34. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
120-139/80-89
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
pyrogens

35. 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.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Tachypnea
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
It increases to push the blood through more rigid pathways.

36. Elevated temperature
The emotions increase hormone secretion - and the body activities required for this increase heat production.
crackles
fever
low BP

37. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Cardiac Output
carotid
shallow or slow breathing
Pons and Medulla of the brainstem

38. Abrupt decline in fever
hypoxemia
Korotkoff sounds Phase V: Silence
Pulse pressure
Crisis

39. Bend of elbow
Brachial
Korotkoff sounds Phase IV: Muffling
higher
Conduction

40. Both strong and weak beats occur within 1 minute
120/70
+2
Irregular
Systolic pressure

41. Axillary temperature are
Kussmaul's respiration
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
about 1 degree lower than oral temperatures
Stroke volume

42. 3 yr old
lysis
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
20-30
from drug therapy - a neurologic problem or dehydration.

43. 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?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Irregular
30-80
Dorsalis pedis

44. 1st stage of fever is?
16-20
Femoral
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
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

45. Side of forehead
Temporal
Korotkoff sounds Phase V: Silence
72 bpm
orthostatic hypertension

46. Strong and regular ( even beats wit moderate force)
arrhythmia
uncooperative patient - children - combative patients - dementia
palpate
+2

47. Average blood pressure should be
hypoxia
16-20
120/70
uncooperative patient - children - combative patients - dementia

48. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Hypothermia
Brachial
Sinoatrial node (SA NODE)
Temperature will remain below 102 degrees with use of hypothermia blanket

49. How does increased body temperature increase the pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
wheeze
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

50. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
oximeter
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
20-30
left Sims position