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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. BP at or lower 90/60.
hypotension
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
60 to 70 mL

2. Diurnal variation BP?
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
Hypothermia
Cheyenne-Stokes
blood pressure is lowest in the morning. and higher in the afternoone

3. The volume of blood pushed into the aorta per heartbeat.
Stroke volume
Korotkoff sounds Phase II Swishing
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

4. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
stridor
palpate
Korotkoff sounds Phase IV: Muffling
dyspnea

5. When should rectal temperatures be used?
ausculatation
Dorsalis pedis
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.
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

6. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Conduction
97.5 to 99.5
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.
Korotkoff sounds Phase IV: Muffling

7. What patients should not use a glass thermometer orally?
uncooperative patient - children - combative patients - dementia
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Femoral
140-159/90-99

8. By measuring the blood pressure you obtain vital info about what?
Stroke volume
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
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
systolic pressure indicated by faint - clear sound that gradually grow louder.

9. Pulse lower than 60 beats per minute
bradycardia
low BP
hypotension
constant

10. Stage 2 hypertension
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
^160/^100
Tachypnea
Pulse

11. What are the 5 vital signs?
Blood pressure increases because there is more volume of blood in the vascular system.
12-20
Korotkoff sounds Phase IV: Muffling
temperature - pulse - respiration - blood pressure - and pain level.

12. 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.
hypoxemia
intermittent
cardiac patients or patients who have had rectal surgery.
bradycardia

13. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
uncooperative patient - children - combative patients - dementia
Korotkoff sounds
hypotension
96.5 to 97.5

14. 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.
Hyperthermia related to infection or excessive heat exposure
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Posterior tibial

15. If the cardiac output falls what will happen to the BP?
It will also fall
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
+1
Core Temperature

16. A normal - relaxed breathing pattern
140-159/90-99
Cheyenne-Stokes
Eupnea
oximetry

17. Drop in blood pressure when arising to a standing position.
blood pressure is lowest in the morning. and higher in the afternoone
constant
hyperoxia
orthostatic hypertension

18. High oxygen
30-80
hyperoxia
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.
The emotions increase hormone secretion - and the body activities required for this increase heat production.

19. 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?
hypoxemia
lysis
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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.

20. What should you do if you cannot determine BP by ausculation?
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 Output
absent
Pedal pulse

21. How is shock caused?
Dorsalis pedis
orthostatic hypertension
Acute anxiety stimulate the nervous system - raising the pulse.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

22. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
Dorsalis pedis
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
oximeter
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

23. Absence of breathing
hyperoxia
+3
apnea
120/70

24. Side of forehead
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Stertor
Hypothermia
Temporal

25. How does age affect pulse?
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.
72 bpm
Feeble
The pulse rate gradually diminishes from birth to adulthood

26. 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
Sinoatrial node (SA NODE)
Nursing interventions to reduce fever
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
+1

27. Bend of knee
about 1 degree lower than oral temperatures
popliteal
Stertor
ausculatation

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

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29. How does menstrual cycle and pregnancy raise the body's temperature?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Hyperventilation
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.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

30. Measurement of oxygen
oximetry
from drug therapy - a neurologic problem or dehydration.
lysis
hypoxemia

31. Sex BP?
Core Temperature
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
males have higher bp - until menopause then they are the same
the rate - the rhythm - and volume

32. 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
Irregular
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.
Pedal pulse
Apical

33. The average temperature in the older adult
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.
96.5 to 97.5
absent
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.

34. Heart
Korotkoff sounds Phase V: Silence
Apical
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Rhonchi

35. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
Convection
the lungs
Hypothermia
+2

36. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
constant
systolic pressure indicated by faint - clear sound that gradually grow louder.
in the alveoli - tiny thin-walled sacs
Korotkoff sounds

37. Side of wrist
Diastolic pressure
crackles
Radial
popliteal

38. Elevated temperature
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.
temperature - pulse - respiration - blood pressure - and pain level.
fever
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.

39. Slow and shallow breathing - leads to hypoxemia.
bradypnea
Crisis
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Posterior tibial

40. What affects does aging do to the respiratory rate?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Systolic pressure
Biot's respirations
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

41. Head injury BP?
Hyperventilation
Conduction
+3
raises BP.

42. Barely palpable
Conduction
Posterior tibial
hypotension
Feeble

43. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
about 1 degree lower than oral temperatures
96.5 to 97.5
Korotkoff sounds Phase III: Knocking
Diastolic pressure

44. Disappearance of sound. (marks diastolic pressure in adults)
Korotkoff sounds Phase V: Silence
hypertension
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
stridor

45. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
bradycardia
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.
absent
It increases to push the blood through more rigid pathways.

46. Does the respiration rate increase or decrease during fever?
systolic pressure indicated by faint - clear sound that gradually grow louder.
Sinoatrial node (SA NODE)
from drug therapy - a neurologic problem or dehydration.
Increases as body tries to remove excess heat

47. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
about 1 degree lower than oral temperatures
Temperature will remain below 102 degrees with use of hypothermia blanket
BMR
wheeze

48. The pulse rate multiplied by the stroke volume. This is the amount of blood pumped by the left ventricle in 1 minute. Averaging at about 5mL per minute.
Stertor
Systolic pressure
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Cardiac Output

49. What happens to the blood if overhydration occurs?
Kussmaul's respiration
Blood pressure increases because there is more volume of blood in the vascular system.
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.
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

50. Are infants blood pressure low or high?
low
Stroke Volume
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Hypothermia