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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. 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.
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
males have higher bp - until menopause then they are the same
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.

2. State of insufficient oxygen
raises BP.
hypoxia
systolic pressure indicated by faint - clear sound that gradually grow louder.
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.

3. 3rd stage of fever?
hypoxemia
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
72 bpm
shallow or slow breathing

4. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
Vascular resistance drops and the blood pressure decreases
The pulse rate gradually diminishes from birth to adulthood
^160/^100
dyspnea

5. Slow and shallow breathing - leads to hypoxemia.
Hypothermia
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
bradypnea
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

6. Heart
20-30
Apical
hypoxia
oximetry

7. Gradual return to a normal temperature
lysis
Vascular resistance drops and the blood pressure decreases
pyrogens
Korotkoff sounds Phase V: Silence

8. Low oxygen
hypoxia
Crisis
Systolic pressure
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

9. Healthly adult
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.
12-20
higher
wheeze

10. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
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
Systolic pressure
Stroke Volume
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.

11. How does age affect pulse?
The pulse rate gradually diminishes from birth to adulthood
higher
Korotkoff sounds
pyrogens

12. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
hypoxia
men - African Americans - under a lot of stress - obese
Convection
stridor

13. Air movemtn causes heat to be transferred from the skin to the air molecules.
Convection
Stroke Volume
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
arrhythmia

14. 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 lower than oral temperatures
remittent
140-159/90-99
+3

15. What affects does aging do to the respiratory rate?
uncooperative patient - children - combative patients - dementia
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
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.
120/80

16. 2nd stage of fever is?
ausculatation
+2
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.
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.

17. Elevated temperature
+3
Kussmaul's respiration
hypertension
fever

18. Excessive sweat production
Diaphoresis
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
120/80

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

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20. Side of neck
tachycardia
Hypothermia
Axillary.
carotid

21. Bend of knee
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.
hypoxia
popliteal
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

22. Substances tat cause fever
stridor
pyrogens
about 1 degree lower than oral temperatures
Korotkoff sounds Phase IV: Muffling

23. Fast - deep respirations with abrupt pauses

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24. Weak and regular (even beats wit poor force)
stridor
+1
Cardiac Output
Brachial

25. When is apicial pulse used?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
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.
lysis
Eupnea

26. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
hypoxemia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
wheeze
Sinoatrial node (SA NODE)

27. Symptoms of hypoxia
Pulse pressure
140-159/90-99
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
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

28. Whats the best position to take a rectal temperature?
left Sims position
ausculatation
Blood pressure increases because there is more volume of blood in the vascular system.
Sinoatrial node (SA NODE)

29. This affects the character of the pulse.
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.
Stroke Volume
hypotension
Biot's

30. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
Hyperthermia related to infection or excessive heat exposure
palpate
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.

31. Those at risk for hypothermia include
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.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Crisis
Blood pressure increases because there is more volume of blood in the vascular system.

32. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Pons and Medulla of the brainstem
^160/^100
Diaphoresis
stridor

33. Side of wrist
BMR
Acute anxiety stimulate the nervous system - raising the pulse.
Radial
raises BP.

34. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to 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.
ausculatation
It increases to push the blood through more rigid pathways.
Evaporation

35. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
arrhythmia
Temporal
Cheyenne-Stokes
hyperoxia

36. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
palpate
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
hypoxia
arrhythmia

37. Pulse above 100 beats per minute
tachycardia
carotid
Axillary.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

38. What are the 5 vital signs?
Stertor
It will also fall
thready
temperature - pulse - respiration - blood pressure - and pain level.

39. How does increased body temperature increase the pulse?
hypoxia
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
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
low BP

40. How do emotions increase the pulse rate?
16-20
Acute anxiety stimulate the nervous system - raising the pulse.
hypoxemia
from drug therapy - a neurologic problem or dehydration.

41. What happens to the blood if overhydration occurs?
palpate
absent
Blood pressure increases because there is more volume of blood in the vascular system.
Cheyenne-Stokes

42. Louder knocking sound that occurs wit each heartbeat
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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.
Korotkoff sounds Phase III: Knocking
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

43. Stage 2 hypertension
arrhythmia
^160/^100
blood pressure is lowest in the morning. and higher in the afternoone
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

44. No pulse palpable or heard on ausculation
apnea
absent
Hyperthermia related to infection or excessive heat exposure
Nursing interventions to reduce fever

45. Top of left foot
low
Temporal
Dorsalis pedis
Diastolic pressure

46. What patients should not use a glass thermometer orally?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
uncooperative patient - children - combative patients - dementia
Korotkoff sounds Phase III: Knocking
Hyperthermia related to infection or excessive heat exposure

47. What affects does aging do to the blood pressure?
hypotension
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
low

48. Why would patients experience orthostatic hypotenstion?
from drug therapy - a neurologic problem or dehydration.
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
oximetry
Stroke Volume

49. 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.
left Sims position
Hyperthermia related to infection or excessive heat exposure
constant
hypoxemia

50. What should you do if you cannot determine BP by ausculation?
absent
left Sims position
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.
the lungs