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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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1. Signs and symptoms of shock
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
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.
about 1 degree lower than oral temperatures
in the alveoli - tiny thin-walled sacs

2. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Respiration
hypoxia
Sinoatrial node (SA NODE)
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

3. Heart
+1
Apical
Pulse pressure
Korotkoff sounds Phase IV: Muffling

4. Elderly respiration
120/70
Convection
16-20
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

5. How should respirations be counted?
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
140-159/90-99
Biot's
remittent

6. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
hypotension
16-20
Korotkoff sounds Phase IV: Muffling

7. Gradual return to a normal temperature
Hypothermia
bradypnea
lysis
hyperoxia

8. Weak and may be irregular
Korotkoff sounds Phase III: Knocking
palpate
thready
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

9. What happens to the blood if overhydration occurs?
Blood pressure increases because there is more volume of blood in the vascular system.
bradycardia
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
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

10. Enviromental temperature BP?
left Sims position
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Respiration
Irregular

11. When is apicial pulse used?
Axillary.
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.
Conduction
Biot's respirations

12. Blood pressure for any adult should be no higher than
Posterior tibial
men - African Americans - under a lot of stress - obese
from drug therapy - a neurologic problem or dehydration.
120/80

13. Louder knocking sound that occurs wit each heartbeat
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.
Hyperventilation
Korotkoff sounds Phase III: Knocking
remittent

14. Bend of elbow
men - African Americans - under a lot of stress - obese
Brachial
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.
raises BP.

15. Elevated temperature
fever
Korotkoff sounds Phase III: Knocking
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
bradypnea

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

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17. What characteristics should be noted when checking the pulse?
palpate
the rate - the rhythm - and volume
arrhythmia
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

18. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
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.
shallow or slow breathing
Femoral
Hypothermia

19. High BP
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
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
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
hypertension

20. 3 yr old
Korotkoff sounds
Vascular resistance drops and the blood pressure decreases
20-30
hypotension

21. Average pulse rate for an adult
crackles
72 bpm
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
pyrogens

22. Pulse above 100 beats per minute
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
+2
Diaphoresis
tachycardia

23. State of insufficient oxygen
Nursing interventions to reduce fever
bradypnea
hypoxia
low BP

24. How do you measure the apical pulse?
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.
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
Korotkoff sounds Phase III: Knocking
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

25. How does disease increase the body's 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.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
hypoxia
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

26. By measuring the blood pressure you obtain vital info about what?
Cheyenne-Stokes
systolic pressure indicated by faint - clear sound that gradually grow louder.
Cardiac Output
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

27. Gas exchange in the blood occurs where?
the rate - the rhythm - and volume
in the alveoli - tiny thin-walled sacs
Rhonchi
20-30

28. This affects the character of the pulse.
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.
Stroke Volume
orthostatic hypertension
males have higher bp - until menopause then they are the same

29. High oxygen
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
hyperoxia
Convection
Hyperthermia related to infection or excessive heat exposure

30. Low oxygen
Korotkoff sounds Phase V: Silence
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Increases as body tries to remove excess heat
hypoxia

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

32. Hearing
Pulse pressure
Relapsing
ausculatation
Stroke volume

33. Obtaining the correct size for a cuff for BP?
Conduction
Korotkoff sounds Phase II Swishing
3 in the right lung and 2 lobes in the left
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

34. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
30-80
Systolic pressure
oximeter
oximetry

35. 2nd stage of fever is?
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.
Temperature will remain below 102 degrees with use of hypothermia blanket
constant
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

36. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
+3
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.
BMR
Rhonchi

37. What affects does aging do to the respiratory rate?
Nursing interventions to reduce fever
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
the blood pressure will rise in order to push the blood along.
60 to 70 mL

38. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
hypoxemia
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.
dyspnea
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

39. Decreased levels of oxygen in the blood - often seen in patients wo are under medical sedation - who are recovering from anesthesia or abdominal surgery - or who are in a weak or debiliated condition.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
hypoxemia
ausculatation
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.

40. How do emotions increase the pulse rate?
Acute anxiety stimulate the nervous system - raising the pulse.
Relapsing
Diastolic pressure
constant

41. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
stridor
low BP
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

42. Are infants blood pressure low or high?
hypotension
low
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
low BP

43. Breathing is an involuntary automatic function controlled by the respiratory center located where?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Pons and Medulla of the brainstem
140-159/90-99
Rhonchi

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

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45. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
thready
Core Temperature
hypertension
Rhonchi

46. Fever above 100.2 F
Hypothermia
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
pyrexia
140-159/90-99

47. A normal - relaxed breathing pattern
30-80
Kussmaul's respiration
Temperature will remain below 102 degrees with use of hypothermia blanket
Eupnea

48. 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
in the alveoli - tiny thin-walled sacs
fever
Pedal pulse
stridor

49. Measurement of oxygen
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Kussmaul's respiration
oximetry
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

50. 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.
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.
Tachypnea
60 to 70 mL
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.