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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. What happens when vasodilation occurs?
20-30
Diastolic pressure
orthostatic hypertension
Vascular resistance drops and the blood pressure decreases

2. Side of wrist
uncooperative patient - children - combative patients - dementia
Radial
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.
Sinoatrial node (SA NODE)

3. Gradual return to a normal temperature
BMR
lysis
Pons and Medulla of the brainstem
pyrexia

4. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
BMR
Respiration
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
stridor

5. Measurement of oxygen
It increases to push the blood through more rigid pathways.
3 in the right lung and 2 lobes in the left
about 1 degree lower than oral temperatures
oximetry

6. When the heart contracts How many mLs of blood is propelled into the aorta?
Brachial
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Tachypnea
60 to 70 mL

7. Pulse above 100 beats per minute
12-20
72 bpm
Diaphoresis
tachycardia

8. Excessive sweat production
Diaphoresis
Increases as body tries to remove excess heat
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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.

9. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
The pulse rate gradually diminishes from birth to adulthood
the lungs
pyrexia
low BP

10. Stress & emotions. BP?
Increases as body tries to remove excess heat
constant
orthostatic hypertension
higher

11. Those at risk for hypothermia include
the lungs
Irregular
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
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.

12. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
remittent
Convection
shallow or slow breathing
Korotkoff sounds Phase II Swishing

13. How is shock caused?
constant
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
hyperoxia
raises BP.

14. How does age affect pulse?
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
The pulse rate gradually diminishes from birth to adulthood
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Cardiac Output

15. The maximum pressure exerted on the artery during left ventricular contraction.
Korotkoff sounds
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
oximeter
Systolic pressure

16. How do drugs affect pulse?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Temperature will remain below 102 degrees with use of hypothermia blanket
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Femoral

17. 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.
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.
3 in the right lung and 2 lobes in the left
remittent
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.

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

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19. A normal - relaxed breathing pattern
72 bpm
Eupnea
hypoxia
uncooperative patient - children - combative patients - dementia

20. Average pulse rate for an adult
120-139/80-89
Pulse pressure
about 1 degree higher than oral temperatures
72 bpm

21. By measuring the blood pressure you obtain vital info about what?
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
60 to 70 mL
Sinoatrial node (SA NODE)
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

22. Strong and regular ( even beats wit moderate force)
the lungs
+2
Feeble
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

23. Enviromental temperature BP?
Pons and Medulla of the brainstem
crackles
Stroke volume
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

24. High oxygen
hyperoxia
The pulse rate gradually diminishes from birth to adulthood
in the alveoli - tiny thin-walled sacs
Temporal

25. Hearing
ausculatation
Korotkoff sounds Phase II Swishing
Blood pressure increases because there is more volume of blood in the vascular system.
oximetry

26. 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?
apnea
+1
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Irregular

27. Elevated temperature
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Cheyenne-Stokes
+1
fever

28. 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
dyspnea
Pedal pulse
left Sims position
Respiration

29. The rate at which heat is produced when the body is at rest.
BMR
about 1 degree higher than oral temperatures
Stroke volume
Hypothermia

30. No pulse palpable or heard on ausculation
Hyperventilation
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Tachypnea
absent

31. 1st stage of fever is?
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
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
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.
30-80

32. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Stertor
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.
The pulse rate gradually diminishes from birth to adulthood
the rate - the rhythm - and volume

33. Elderly respiration
16-20
+2
120-139/80-89
men - African Americans - under a lot of stress - obese

34. 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.
140-159/90-99
Respiration
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
Hypothermia

35. Disappearance of sound. (marks diastolic pressure in adults)
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Korotkoff sounds Phase V: Silence
higher

36. How does menstrual cycle and pregnancy raise the body's temperature?
low BP
left Sims position
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
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

37. Stage 1 hypertension
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.
Conduction
140-159/90-99
Brachial

38. Pulse lower than 60 beats per minute
remittent
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Korotkoff sounds Phase IV: Muffling
bradycardia

39. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Korotkoff sounds Phase IV: Muffling
absent
Pedal pulse
intermittent

40. The temperature falls to normal and then rises again in a repeating pattern.
Relapsing
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
uncooperative patient - children - combative patients - dementia
Temporal

41. right arm vs. left arm/ arm vs. leg BP?
systolic pressure indicated by faint - clear sound that gradually grow louder.
pyrogens
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

42. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
bradycardia
apnea
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.

43. Blood pressure for any adult should be no higher than
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Nursing interventions to reduce fever
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
120/80

44. Bend of elbow
carotid
Brachial
Relapsing
ausculatation

45. Groin area
carotid
+1
ausculatation
Femoral

46. Side of forehead
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.
ausculatation
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Temporal

47. State of insufficient oxygen
Tall - slender people mayy ave a slower pulse rate than short - stout persons
hyperoxia
about 1 degree lower than oral temperatures
hypoxia

48. 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
16-20
Conduction
Nursing interventions to reduce fever
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

49. If the cardiac output falls what will happen to the BP?
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.
left Sims position
It will also fall
bradycardia

50. Bend of knee
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Cheyenne-Stokes
bradycardia
popliteal