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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. Blood pressure for any adult should be no higher than
120/70
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
120/80
carotid

2. Air movemtn causes heat to be transferred from the skin to the air molecules.
120/80
Convection
hypoxia
Apical

3. An example of nursing planning
tachycardia
97.5 to 99.5
raises BP.
Temperature will remain below 102 degrees with use of hypothermia blanket

4. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
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.
BMR
Hyperthermia related to infection or excessive heat exposure
Evaporation

5. No pulse palpable or heard on ausculation
crackles
Blood pressure increases because there is more volume of blood in the vascular system.
higher
absent

6. Whats the best position to take a rectal temperature?
Biot's respirations
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
left Sims position
96.5 to 97.5

7. Top of left foot
Dorsalis pedis
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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
Conduction

8. The temperature of the deep tissues of the body
Core Temperature
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
72 bpm
+2

9. How does size affect pulse?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Vascular resistance drops and the blood pressure decreases
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

10. Abrupt decline in fever
Crisis
60 to 70 mL
lysis
Diaphoresis

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

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12. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
men - African Americans - under a lot of stress - obese
Korotkoff sounds
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
constant

13. Korotkoff sounds Phase I: Tapping
It increases to push the blood through more rigid pathways.
systolic pressure indicated by faint - clear sound that gradually grow louder.
Vascular resistance drops and the blood pressure decreases
Eupnea

14. Sex BP?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
males have higher bp - until menopause then they are the same
remittent
Stroke volume

15. Are infants blood pressure low or high?
Biot's respirations
Blood pressure increases because there is more volume of blood in the vascular system.
low
orthostatic hypertension

16. Signs and symptoms of shock
Core Temperature
oximetry
temperature - pulse - respiration - blood pressure - and pain level.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

17. Abnormal - nonmusical sound heard on ausculation of the lungs during inspiration; also called rales. Sound like hair rubbed between the fingers next to the ears.
Rhonchi
the rate - the rhythm - and volume
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
crackles

18. Axillary temperature are
Stroke volume
about 1 degree lower than oral temperatures
lysis
tachycardia

19. 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
^160/^100
Nursing interventions to reduce fever
oximeter
Tachypnea

20. Stress & emotions. BP?
higher
Conduction
carotid
Core Temperature

21. Fever above 100.2 F
20-30
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
pyrexia
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.

22. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Pons and Medulla of the brainstem
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.
arrhythmia
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

23. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
from drug therapy - a neurologic problem or dehydration.
about 1 degree lower than oral temperatures
Acute anxiety stimulate the nervous system - raising the pulse.
wheeze

24. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
shallow or slow breathing
in the alveoli - tiny thin-walled sacs
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Increases as body tries to remove excess heat

25. How do emotions increase the pulse rate?
Acute anxiety stimulate the nervous system - raising the pulse.
Korotkoff sounds Phase IV: Muffling
blood pressure is lowest in the morning. and higher in the afternoone
Pedal pulse

26. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Korotkoff sounds Phase II Swishing
Respiration
Radial
Tall - slender people mayy ave a slower pulse rate than short - stout persons

27. How does disease increase the body's 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.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Evaporation
intermittent

28. How does menstrual cycle and pregnancy raise the body's temperature?
+3
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
low BP

29. People most at risk for hypertension
+2
72 bpm
men - African Americans - under a lot of stress - obese
Radial

30. BP at or lower 90/60.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
hypotension
140-159/90-99
Korotkoff sounds

31. Korotkoff sounds Ausculatatory gap:
Relapsing
the lungs
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Radial

32. Side of neck
uncooperative patient - children - combative patients - dementia
Feeble
carotid
Temperature will remain below 102 degrees with use of hypothermia blanket

33. When the heart contracts How many mLs of blood is propelled into the aorta?
60 to 70 mL
Stroke volume
Korotkoff sounds Phase III: Knocking
men - African Americans - under a lot of stress - obese

34. Inside ankle
Posterior tibial
Nursing interventions to reduce fever
palpate
hypotension

35. What affects does aging do to the blood pressure?
carotid
pyrexia
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

36. Why would patients experience orthostatic hypotenstion?
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
intermittent
crackles
from drug therapy - a neurologic problem or dehydration.

37. 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
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
60 to 70 mL
Diaphoresis

38. Head injury BP?
+3
Korotkoff sounds Phase III: Knocking
96.5 to 97.5
raises BP.

39. What characteristics should be noted when checking the pulse?
the rate - the rhythm - and volume
Stroke Volume
Cardiac Output
Irregular

40. Barely palpable
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
temperature - pulse - respiration - blood pressure - and pain level.
thready
Feeble

41. Weak and regular (even beats wit poor force)
+1
Korotkoff sounds Phase IV: Muffling
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
blood pressure is lowest in the morning. and higher in the afternoone

42. Both strong and weak beats occur within 1 minute
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
cardiac patients or patients who have had rectal surgery.
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.
Irregular

43. Risk for prolonged hypertension
popliteal
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
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

44. How do drugs affect pulse?
Tachypnea
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
ausculatation
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

45. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Pulse
Eupnea
Temporal

46. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
Core Temperature
97.5 to 99.5
in the alveoli - tiny thin-walled sacs
oximeter

47. What are the 5 vital signs?
temperature - pulse - respiration - blood pressure - and pain level.
Tachypnea
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
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.

48. Pulse above 100 beats per minute
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
tachycardia
Temperature will remain below 102 degrees with use of hypothermia blanket
Posterior tibial

49. When should rectal temperatures be used?
97.5 to 99.5
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
The pulse rate gradually diminishes from birth to adulthood

50. Low oxygen
Feeble
Tachypnea
constant
hypoxia