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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. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Blood pressure increases because there is more volume of blood in the vascular system.
Korotkoff sounds Phase IV: Muffling
12-20
Radial

2. Are infants blood pressure low or high?
Conduction
Biot's
low
+1

3. What are the 5 vital signs?
crackles
temperature - pulse - respiration - blood pressure - and pain level.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Temporal

4. BP at or lower 90/60.
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
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
Crisis

5. Average blood pressure should be
temperature - pulse - respiration - blood pressure - and pain level.
120/70
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

6. A normal - relaxed breathing pattern
Apical
popliteal
Korotkoff sounds
Eupnea

7. Stress & emotions. BP?
higher
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.
+3
Posterior tibial

8. Elderly respiration
16-20
blood pressure is lowest in the morning. and higher in the afternoone
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
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.

9. Obtaining the correct size for a cuff for BP?
+3
Dorsalis pedis
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Stertor

10. Murmur or swishing sounds that increase as the cuff is deflated
Korotkoff sounds Phase II Swishing
BMR
raises BP.
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.

11. Why would patients experience orthostatic hypotenstion?
from drug therapy - a neurologic problem or dehydration.
low
16-20
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

12. 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
Temporal
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Hyperventilation
Korotkoff sounds Phase IV: Muffling

13. The difference between the systolic pressure and the diastolic pressure
Pulse pressure
temperature - pulse - respiration - blood pressure - and pain level.
Respiration
hypotension

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

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15. Rectal temperature are
about 1 degree higher than oral temperatures
bradycardia
absent
palpate

16. Drop in blood pressure when arising to a standing position.
Stroke Volume
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
orthostatic hypertension
pyrogens

17. When should rectal temperatures NOT be used?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
97.5 to 99.5
cardiac patients or patients who have had rectal surgery.
+3

18. How does age affect pulse?
The pulse rate gradually diminishes from birth to adulthood
hypoxia
Stertor
carotid

19. Measurement of oxygen
Respiration
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.
+3
oximetry

20. How does menstrual cycle and pregnancy raise the body's temperature?
temperature - pulse - respiration - blood pressure - and pain level.
popliteal
Temperature will remain below 102 degrees with use of hypothermia blanket
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

21. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
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.
3 in the right lung and 2 lobes in the left
Nursing interventions to reduce fever
shallow or slow breathing

22. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Apical
hypertension
the blood pressure will rise in order to push the blood along.
wheeze

23. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
oximeter
bradypnea
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

24. Gradual return to a normal temperature
hypoxia
Brachial
Hypothermia
lysis

25. What characteristics should be noted when checking the pulse?
lysis
hypoxemia
the rate - the rhythm - and volume
oximetry

26. Low oxygen
uncooperative patient - children - combative patients - dementia
16-20
hypertension
hypoxia

27. Newborn
Stertor
systolic pressure indicated by faint - clear sound that gradually grow louder.
30-80
about 1 degree lower than oral temperatures

28. An example of a nursing diagnoses
Respiration
Hyperthermia related to infection or excessive heat exposure
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.
in the alveoli - tiny thin-walled sacs

29. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
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
stridor
absent
hypoxia

30. 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.
remittent
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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.

31. When warm skin touches a cool object - heat is lost to the object.
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.
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.
crackles
Conduction

32. Excessive sweat production
Diaphoresis
Increases as body tries to remove excess heat
the blood pressure will rise in order to push the blood along.
lysis

33. How does emotional stress raise the body's temperature?
Diaphoresis
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
The emotions increase hormone secretion - and the body activities required for this increase heat production.
carotid

34. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
16-20
absent
Stroke volume

35. Stage 2 hypertension
^160/^100
oximetry
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
palpate

36. 3 yr old
males have higher bp - until menopause then they are the same
pyrogens
the blood pressure will rise in order to push the blood along.
20-30

37. Louder knocking sound that occurs wit each heartbeat
Korotkoff sounds Phase III: Knocking
96.5 to 97.5
constant
Temperature will remain below 102 degrees with use of hypothermia blanket

38. How is shock caused?
Pulse pressure
about 1 degree higher than oral temperatures
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.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

39. High oxygen
120-139/80-89
120/80
+3
hyperoxia

40. Korotkoff sounds Phase I: Tapping
Vascular resistance drops and the blood pressure decreases
from drug therapy - a neurologic problem or dehydration.
systolic pressure indicated by faint - clear sound that gradually grow louder.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

41. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Core Temperature
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.
absent

42. Does the respiration rate increase or decrease during fever?
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.
constant
arrhythmia
Increases as body tries to remove excess heat

43. The temperature falls to normal and then rises again in a repeating pattern.
Relapsing
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
orthostatic hypertension
constant

44. Both strong and weak beats occur within 1 minute
intermittent
Irregular
stridor
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

45. How do drugs affect pulse?
in the alveoli - tiny thin-walled sacs
Evaporation
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Cardiac Output

46. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Dorsalis pedis
ausculatation
Pulse pressure
Korotkoff sounds

47. An example of nursing planning
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.
Temperature will remain below 102 degrees with use of hypothermia blanket
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

48. Weak and may be irregular
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
thready
Korotkoff sounds Phase III: Knocking
carotid

49. Absence of breathing
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
apnea
hypoxia
72 bpm

50. Disappearance of sound. (marks diastolic pressure in adults)
Korotkoff sounds Phase V: Silence
Biot's
120/80
20-30