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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

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. An example of a nursing diagnoses
males have higher bp - until menopause then they are the same
Hyperthermia related to infection or excessive heat exposure
Korotkoff sounds Phase II Swishing
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.

2. Blood pressure for any adult should be no higher than
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
120/80
hypoxemia
pyrexia

3. Fever above 100.2 F
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
96.5 to 97.5
pyrexia
about 1 degree lower than oral temperatures

4. Rectal temperature are
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
about 1 degree higher than oral temperatures
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.

5. Sex BP?
carotid
males have higher bp - until menopause then they are the same
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
tachycardia

6. Measurement of oxygen
oximetry
uncooperative patient - children - combative patients - dementia
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.
orthostatic hypertension

7. How does the time of day (circadian rhythm) affect the body's temperature?

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8. 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.
remittent
oximetry
apnea
97.5 to 99.5

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

10. Whats the best position to take a rectal temperature?
96.5 to 97.5
hypoxia
left Sims position
Korotkoff sounds Phase IV: Muffling

11. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
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.
left Sims position
the lungs

12. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
120/70
Korotkoff sounds Phase IV: Muffling
Stroke volume
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.

13. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
bradycardia
oximeter
Hyperthermia related to infection or excessive heat exposure
hyperoxia

14. The difference between the systolic pressure and the diastolic pressure
^160/^100
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.
Pulse pressure
left Sims position

15. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
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.
low BP
Korotkoff sounds Phase III: Knocking
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

16. Head injury BP?
raises BP.
Blood pressure increases because there is more volume of blood in the vascular system.
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 pulse rate gradually diminishes from birth to adulthood

17. A normal - relaxed breathing pattern
Korotkoff sounds Phase II Swishing
+3
Pons and Medulla of the brainstem
Eupnea

18. Side of wrist
Kussmaul's respiration
absent
left Sims position
Radial

19. How does emotional stress raise the body's temperature?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Evaporation
The emotions increase hormone secretion - and the body activities required for this increase heat production.
hypoxia

20. Those at risk for hypothermia include
3 in the right lung and 2 lobes in the left
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.
It will also fall

21. No pulse palpable or heard on ausculation
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
absent
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.
arrhythmia

22. Newborn
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Respiration
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
30-80

23. Korotkoff sounds Ausculatatory gap:
16-20
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
140-159/90-99
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

24. Elevated temperature
absent
Feeble
fever
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

25. right arm vs. left arm/ arm vs. leg BP?
Femoral
absent
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.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

26. How does size affect pulse?
3 in the right lung and 2 lobes in the left
hypertension
16-20
Tall - slender people mayy ave a slower pulse rate than short - stout persons

27. Side of forehead
hypoxemia
arrhythmia
Rhonchi
Temporal

28. Taking axillary temperature
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
Korotkoff sounds Phase II Swishing
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

29. What happens when vasodilation occurs?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Vascular resistance drops and the blood pressure decreases
Korotkoff sounds

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
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Nursing interventions to reduce fever
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
raises BP.

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

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32. What affects does aging do to the respiratory rate?
Apical
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Crisis
Hyperthermia related to infection or excessive heat exposure

33. Weak and regular (even beats wit poor force)
+1
oximeter
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
30-80

34. Obtaining the correct size for a cuff for BP?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
thready
Pulse pressure

35. Enviromental temperature BP?
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Rhonchi

36. How does increased body temperature increase the pulse?
hypotension
oximetry
Posterior tibial
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

37. When should rectal temperatures be used?
96.5 to 97.5
Dorsalis pedis
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
Vascular resistance drops and the blood pressure decreases

38. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
palpate
Evaporation
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Tachypnea

39. How do drugs affect pulse?
in the alveoli - tiny thin-walled sacs
systolic pressure indicated by faint - clear sound that gradually grow louder.
hypotension
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

40. BP at or lower 90/60.
Systolic pressure
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
hypotension
cardiac patients or patients who have had rectal surgery.

41. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Biot's
Cheyenne-Stokes
Acute anxiety stimulate the nervous system - raising the 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.

42. Healthly adult
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
the rate - the rhythm - and volume
12-20
120/70

43. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
Hyperventilation
constant
It increases to push the blood through more rigid pathways.
wheeze

44. Diurnal variation BP?
blood pressure is lowest in the morning. and higher in the afternoone
Tachypnea
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Hyperventilation

45. Korotkoff sounds Phase I: Tapping
Relapsing
Pons and Medulla of the brainstem
Cardiac Output
systolic pressure indicated by faint - clear sound that gradually grow louder.

46. How does physical exercise raise the body's temperature?
Systolic pressure
16-20
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.
Biot's respirations

47. Substances tat cause fever
pyrogens
Dorsalis pedis
Cardiac Output
The pulse rate gradually diminishes from birth to adulthood

48. Taking a rectal temperature
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
16-20
apnea

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

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50. 3 yr old
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
from drug therapy - a neurologic problem or dehydration.
20-30
temperature - pulse - respiration - blood pressure - and pain level.