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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 will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
Diaphoresis
bradypnea
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.
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. Drop in blood pressure when arising to a standing position.
Vascular resistance drops and the blood pressure decreases
orthostatic hypertension
Sinoatrial node (SA NODE)
Stroke volume

3. How does emotional stress raise the body's temperature?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Feeble
Evaporation
hyperoxia

4. Low oxygen
palpate
hypoxia
Biot's
It will also fall

5. Barely palpable
Feeble
BMR
Korotkoff sounds Phase II Swishing
Irregular

6. Murmur or swishing sounds that increase as the cuff is deflated
hypotension
Conduction
higher
Korotkoff sounds Phase II Swishing

7. Slow and shallow breathing - leads to hypoxemia.
oximeter
bradypnea
30-80
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

8. The difference between the systolic pressure and the diastolic pressure
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
hypertension
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Pulse pressure

9. Stage 1 hypertension
140-159/90-99
shallow or slow breathing
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.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

10. Whats the best position to take a rectal temperature?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
left Sims position
Diastolic pressure
Femoral

11. Does the respiration rate increase or decrease during fever?
fever
Increases as body tries to remove excess heat
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.
Hypothermia

12. Absence of breathing
Korotkoff sounds Phase II Swishing
BMR
72 bpm
apnea

13. 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.
crackles
in the alveoli - tiny thin-walled sacs
Axillary.
systolic pressure indicated by faint - clear sound that gradually grow louder.

14. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
Irregular
Korotkoff sounds Phase IV: Muffling
dyspnea
fever

15. 2nd stage of fever is?
Apical
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.
Systolic pressure
Vascular resistance drops and the blood pressure decreases

16. How is shock caused?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
raises BP.
Apical
tachycardia

17. 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
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Nursing interventions to reduce fever
Femoral
blood pressure is lowest in the morning. and higher in the afternoone

18. How does disease increase the body's temperature?
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
It will also fall
140-159/90-99
120-139/80-89

19. Those at risk for hypothermia include
Pedal pulse
Nursing interventions to reduce fever
Hypothermia
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.

20. How do you measure the apical pulse?
It increases to push the blood through more rigid pathways.
Kussmaul's respiration
Nursing interventions to reduce 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

21. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Stertor
Korotkoff sounds Phase II Swishing
It increases to push the blood through more rigid pathways.

22. 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
Korotkoff sounds Phase III: Knocking
Hyperventilation
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Rhonchi

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

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24. How do emotions increase the pulse rate?
Acute anxiety stimulate the nervous system - raising the pulse.
Stroke volume
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Brachial

25. Lobes in the lungs?
3 in the right lung and 2 lobes in the left
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
hypotension
hypoxia

26. What patients should not use a glass thermometer orally?
Conduction
+1
Temporal
uncooperative patient - children - combative patients - dementia

27. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
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.
Femoral
Korotkoff sounds Phase IV: Muffling
Irregular

28. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Radial
wheeze
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Apical

29. Symptoms of hypoxia
Korotkoff sounds Phase III: Knocking
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Korotkoff sounds Phase II Swishing

30. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
stridor
males have higher bp - until menopause then they are the same
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

31. Korotkoff sounds Ausculatatory gap:
lysis
systolic pressure indicated by faint - clear sound that gradually grow louder.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

32. Substances tat cause fever
Cheyenne-Stokes
Hypothermia
Hyperthermia related to infection or excessive heat exposure
pyrogens

33. Signs and symptoms of shock
Diastolic pressure
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
The emotions increase hormone secretion - and the body activities required for this increase heat production.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

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

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35. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Kussmaul's respiration
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.
shallow or slow breathing
30-80

36. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
Cheyenne-Stokes
stridor
12-20
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

37. Measurement of oxygen
oximetry
Biot's respirations
Irregular
Rhonchi

38. The volume of blood pushed into the aorta per heartbeat.
Stroke volume
pyrexia
Tachypnea
hypotension

39. Bend of knee
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
popliteal
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.
Core Temperature

40. How does age affect pulse?
The pulse rate gradually diminishes from birth to adulthood
Biot's
Hypothermia
Tall - slender people mayy ave a slower pulse rate than short - stout persons

41. Taking axillary 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.
systolic pressure indicated by faint - clear sound that gradually grow louder.
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
the rate - the rhythm - and volume

42. Weak and may be irregular
arrhythmia
thready
constant
12-20

43. Blood pressure for any adult should be no higher than
120/80
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Tachypnea
Pons and Medulla of the brainstem

44. Side of neck
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Biot's
Dorsalis pedis
carotid

45. By measuring the blood pressure you obtain vital info about what?
Dorsalis pedis
the blood pressure will rise in order to push the blood along.
Femoral
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

46. Both strong and weak beats occur within 1 minute
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Irregular
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Acute anxiety stimulate the nervous system - raising the pulse.

47. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Stroke Volume
constant
Cheyenne-Stokes
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

48. Full and bounding (even beats wit strong force)
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.
Temperature will remain below 102 degrees with use of hypothermia blanket
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
+3

49. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
low 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.
Pedal pulse
Systolic pressure

50. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
in the alveoli - tiny thin-walled sacs
wheeze
intermittent
Korotkoff sounds

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Measuring Vital Signs

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