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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.
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. Prehypertension
120-139/80-89
Femoral
about 1 degree lower than oral temperatures
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

2. What are the 5 vital signs?
Rhonchi
temperature - pulse - respiration - blood pressure - and pain level.
Acute anxiety stimulate the nervous system - raising the pulse.
wheeze

3. Enviromental temperature BP?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
16-20
pyrexia

4. How does disease increase the body's temperature?
3 in the right lung and 2 lobes in the left
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
bradycardia
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.

5. 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.
palpate
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

6. High oxygen
about 1 degree higher than oral temperatures
men - African Americans - under a lot of stress - obese
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
hyperoxia

7. What happens when vasodilation occurs?
16-20
Acute anxiety stimulate the nervous system - raising the pulse.
Vascular resistance drops and the blood pressure decreases
hypoxia

8. Are infants blood pressure low or high?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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.
3 in the right lung and 2 lobes in the left
low

9. Excessive sweat production
Pulse pressure
Diaphoresis
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
lysis

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

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11. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Evaporation
Increases as body tries to remove excess heat
Korotkoff sounds
systolic pressure indicated by faint - clear sound that gradually grow louder.

12. What should you do if you cannot determine BP by ausculation?
97.5 to 99.5
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Stertor
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.

13. Korotkoff sounds Phase I: Tapping
systolic pressure indicated by faint - clear sound that gradually grow louder.
Korotkoff sounds Phase IV: Muffling
ausculatation
Brachial

14. Pulse above 100 beats per minute
Evaporation
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.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
tachycardia

15. Taking a rectal temperature
Stroke volume
Blood pressure increases because there is more volume of blood in the vascular system.
bradycardia
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

16. Inside ankle
Posterior tibial
the rate - the rhythm - and volume
hypoxia
hyperoxia

17. How does emotional stress raise the body's temperature?
hypotension
cardiac patients or patients who have had rectal surgery.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
^160/^100

18. What affects does aging do to the blood 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
30-80
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
dyspnea

19. Gas exchange in the blood occurs where?
Core Temperature
systolic pressure indicated by faint - clear sound that gradually grow louder.
Pons and Medulla of the brainstem
in the alveoli - tiny thin-walled sacs

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

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21. Gradual return to a normal temperature
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Femoral
Pons and Medulla of the brainstem
lysis

22. Elderly respiration
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
16-20
intermittent
popliteal

23. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Temporal
Korotkoff sounds Phase IV: Muffling
shallow or slow breathing
lysis

24. How does menstrual cycle and pregnancy raise the body's temperature?
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
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Cheyenne-Stokes
Crisis

25. 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
oximetry
Temporal
Nursing interventions to reduce fever
lysis

26. Substances tat cause fever
Convection
97.5 to 99.5
pyrogens
BMR

27. Korotkoff sounds Ausculatatory gap:
absent
systolic pressure indicated by faint - clear sound that gradually grow louder.
Irregular
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

28. Side of neck
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.
crackles
Nursing interventions to reduce fever
carotid

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

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30. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Cardiac Output
Cheyenne-Stokes
males have higher bp - until menopause then they are the same
apnea

31. An example of nursing planning
Temperature will remain below 102 degrees with use of hypothermia blanket
Hyperthermia related to infection or excessive heat exposure
low
Korotkoff sounds Phase V: Silence

32. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
Diastolic pressure
the blood pressure will rise in order to push the blood along.
Hyperthermia related to infection or excessive heat exposure
16-20

33. How is pulse best found?
fever
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
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
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.

34. The average temperature in the older adult
in the alveoli - tiny thin-walled sacs
dyspnea
96.5 to 97.5
Radial

35. Stage 1 hypertension
hypoxia
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.
palpate
140-159/90-99

36. Pulse lower than 60 beats per minute
systolic pressure indicated by faint - clear sound that gradually grow louder.
Kussmaul's respiration
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
bradycardia

37. Alternating rise and fall of the temperature.
Hyperventilation
arrhythmia
Stroke volume
intermittent

38. 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.
absent
orthostatic hypertension
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

39. Bend of elbow
Hyperventilation
Brachial
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.
bradypnea

40. An example of a nursing diagnoses
Blood pressure increases because there is more volume of blood in the vascular system.
Hyperthermia related to infection or excessive heat exposure
140-159/90-99
remittent

41. Why would patients experience orthostatic hypotenstion?
^160/^100
oximeter
Biot's
from drug therapy - a neurologic problem or dehydration.

42. Side of wrist
Radial
Tall - slender people mayy ave a slower pulse rate than short - stout persons
low
shallow or slow breathing

43. A pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled - causing te blood level of carbon dioxide to fall. this condition is seen after sever exertion - during high levels of anxiety o
ausculatation
lysis
140-159/90-99
Hyperventilation

44. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
120/80
20-30
temperature - pulse - respiration - blood pressure - and pain level.
stridor

45. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
in the alveoli - tiny thin-walled sacs
120-139/80-89
wheeze
the blood pressure will rise in order to push the blood along.

46. The maximum pressure exerted on the artery during left ventricular contraction.
bradycardia
Systolic pressure
+3
72 bpm

47. Absence of breathing
apnea
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
3 in the right lung and 2 lobes in the left
+2

48. Does the respiration rate increase or decrease during fever?
16-20
Increases as body tries to remove excess heat
Systolic pressure
Pulse pressure

49. How does age affect pulse?
Feeble
higher
Core Temperature
The pulse rate gradually diminishes from birth to adulthood

50. How does external respiration occur?
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.
Apical
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
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes