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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. The temperature falls to normal and then rises again in a repeating pattern.
Feeble
Relapsing
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
temperature - pulse - respiration - blood pressure - and pain level.

2. Alternating rise and fall of the temperature.
temperature - pulse - respiration - blood pressure - and pain level.
Sinoatrial node (SA NODE)
Korotkoff sounds Phase IV: Muffling
intermittent

3. Does the respiration rate increase or decrease during fever?
Increases as body tries to remove excess heat
The pulse rate gradually diminishes from birth to adulthood
Diaphoresis
crackles

4. How do you measure the apical pulse?
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 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.
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
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

5. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Convection
fever
absent
Stertor

6. When is apicial pulse used?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
^160/^100
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.
96.5 to 97.5

7. 2nd stage of fever is?
bradypnea
arrhythmia
lysis
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.

8. 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
dyspnea
Nursing interventions to reduce fever
Hyperventilation
blood pressure is lowest in the morning. and higher in the afternoone

9. Both strong and weak beats occur within 1 minute
Korotkoff sounds Phase IV: Muffling
Irregular
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Diaphoresis

10. The maximum pressure exerted on the artery during left ventricular contraction.
Stroke Volume
Korotkoff sounds Phase II Swishing
Relapsing
Systolic pressure

11. 3 yr old
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
12-20
low
20-30

12. What affects does aging do to the blood pressure?
It will also fall
the lungs
30-80
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

13. Measurement of oxygen
Brachial
oximetry
wheeze
30-80

14. When should rectal temperatures NOT be used?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
pyrexia
Stroke volume
cardiac patients or patients who have had rectal surgery.

15. Absence of breathing
hypoxia
apnea
Dorsalis pedis
Korotkoff sounds Phase V: Silence

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

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17. This affects the character of the pulse.
about 1 degree higher than oral temperatures
Stroke Volume
Pedal pulse
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.

18. What affects does aging do to the respiratory rate?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Korotkoff sounds Phase III: Knocking
Pedal pulse
Rhonchi

19. Whats the best position to take a rectal temperature?
Systolic pressure
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
The emotions increase hormone secretion - and the body activities required for this increase heat production.
left Sims position

20. 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
Cheyenne-Stokes
ausculatation
arrhythmia

21. What patients should not use a glass thermometer orally?
cardiac patients or patients who have had rectal surgery.
uncooperative patient - children - combative patients - dementia
Convection
hypoxia

22. Side of wrist
Radial
12-20
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
bradypnea

23. The rate at which heat is produced when the body is at rest.
Irregular
BMR
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
about 1 degree lower than oral temperatures

24. What are the 5 vital signs?
Biot's
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
temperature - pulse - respiration - blood pressure - and pain level.
tachycardia

25. Inside ankle
palpate
Posterior tibial
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
120-139/80-89

26. An example of nursing planning
Temperature will remain below 102 degrees with use of hypothermia blanket
Tall - slender people mayy ave a slower pulse rate than short - stout persons
120/80
12-20

27. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
about 1 degree lower than oral temperatures
palpate
the lungs
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.

28. What characteristics should be noted when checking the pulse?
Korotkoff sounds
the rate - the rhythm - and volume
ausculatation
16-20

29. How does age affect pulse?
Feeble
Irregular
The pulse rate gradually diminishes from birth to adulthood
bradycardia

30. State of insufficient oxygen
men - African Americans - under a lot of stress - obese
hypoxia
Radial
97.5 to 99.5

31. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Diaphoresis
wheeze
Korotkoff sounds Phase V: Silence
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.

32. 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.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Hypothermia
It will also fall
Hyperthermia related to infection or excessive heat exposure

33. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
hypotension
Pons and Medulla of the brainstem

34. Average blood pressure should be
120/70
+3
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
the blood pressure will rise in order to push the blood along.

35. Enviromental temperature BP?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
about 1 degree higher than oral temperatures
Kussmaul's respiration
hypotension

36. Taking a rectal temperature
+1
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.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
dyspnea

37. The volume of blood pushed into the aorta per heartbeat.
Pons and Medulla of the brainstem
120/80
Radial
Stroke volume

38. Disappearance of sound. (marks diastolic pressure in adults)
Cardiac Output
Korotkoff sounds Phase V: Silence
bradypnea
carotid

39. Stress & emotions. BP?
higher
BMR
96.5 to 97.5
Evaporation

40. Excessive sweat production
systolic pressure indicated by faint - clear sound that gradually grow louder.
Diaphoresis
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Cardiac Output

41. Stage 1 hypertension
Tachypnea
Korotkoff sounds Phase IV: Muffling
140-159/90-99
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

42. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
fever
dyspnea
Diastolic pressure
hypertension

43. Gas exchange in the blood occurs where?
Nursing interventions to reduce fever
in the alveoli - tiny thin-walled sacs
Irregular
left Sims position

44. 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.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Convection
3 in the right lung and 2 lobes in the left

45. Are infants blood pressure low or high?
Crisis
about 1 degree lower than oral temperatures
low
apnea

46. Bend of elbow
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
Stroke volume
Brachial
97.5 to 99.5

47. How do emotions increase 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
Acute anxiety stimulate the nervous system - raising the pulse.
hypoxia
The pulse rate gradually diminishes from birth to adulthood

48. Pulse lower than 60 beats per minute
bradycardia
Pons and Medulla of the brainstem
apnea
Vascular resistance drops and the blood pressure decreases

49. 3rd stage of fever?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
hypoxemia
shallow or slow breathing
3 in the right lung and 2 lobes in the left

50. Fast - deep respirations with abrupt pauses

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