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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 patients should not use a glass thermometer orally?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
uncooperative patient - children - combative patients - dementia
Sinoatrial node (SA NODE)
Evaporation

2. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
Radial
Hypothermia
about 1 degree higher than oral temperatures
the blood pressure will rise in order to push the blood along.

3. Taking axillary temperature
uncooperative patient - children - combative patients - dementia
Tachypnea
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

4. How does external respiration occur?
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
Korotkoff sounds Phase III: Knocking
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.
60 to 70 mL

5. How does age affect pulse?
men - African Americans - under a lot of stress - obese
The pulse rate gradually diminishes from birth to adulthood
dyspnea
thready

6. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
wheeze
Radial
97.5 to 99.5
The pulse rate gradually diminishes from birth to adulthood

7. Signs and symptoms of shock
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Stroke volume
It will also fall

8. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
constant
Korotkoff sounds Phase V: Silence
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

9. BP at or lower 90/60.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
hypotension
bradycardia
fever

10. When the heart contracts How many mLs of blood is propelled into the aorta?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
thready
60 to 70 mL
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.

11. What happens when vasodilation occurs?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
the blood pressure will rise in order to push the blood along.
Vascular resistance drops and the blood pressure decreases
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.

12. The pulse rate multiplied by the stroke volume. This is the amount of blood pumped by the left ventricle in 1 minute. Averaging at about 5mL per minute.
Cardiac Output
the rate - the rhythm - and volume
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.
stridor

13. How is shock caused?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
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.
intermittent
16-20

14. Louder knocking sound that occurs wit each heartbeat
Hypothermia
hypotension
Korotkoff sounds Phase III: Knocking
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

15. Korotkoff sounds Phase I: Tapping
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
crackles
systolic pressure indicated by faint - clear sound that gradually grow louder.
Tachypnea

16. Both strong and weak beats occur within 1 minute
Biot's respirations
Irregular
Femoral
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

17. 2nd stage of fever is?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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.
Acute anxiety stimulate the nervous system - raising the pulse.
cardiac patients or patients who have had rectal surgery.

18. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Apical
120/70
Pons and Medulla of the brainstem
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

19. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
stridor
hypoxemia
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.
the rate - the rhythm - and volume

20. People most at risk for hypertension
Nursing interventions to reduce fever
men - African Americans - under a lot of stress - obese
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Kussmaul's respiration

21. High oxygen
Stroke Volume
hyperoxia
120/80
cardiac patients or patients who have had rectal surgery.

22. Pulse above 100 beats per minute
Hypothermia
tachycardia
hypoxia
Pulse

23. Strong and regular ( even beats wit moderate force)
Diastolic pressure
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.
+2
men - African Americans - under a lot of stress - obese

24. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
Diaphoresis
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
120-139/80-89
120/80

25. Heart
Blood pressure increases because there is more volume of blood in the vascular system.
Temperature will remain below 102 degrees with use of hypothermia blanket
Apical
72 bpm

26. Hearing
men - African Americans - under a lot of stress - obese
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
It will also fall
ausculatation

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

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28. Lobes in the lungs?
Pons and Medulla of the brainstem
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
blood pressure is lowest in the morning. and higher in the afternoone
3 in the right lung and 2 lobes in the left

29. Healthly adult
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
Pedal pulse
12-20
Tachypnea

30. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
wheeze
arrhythmia
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.
Conduction

31. Sex BP?
20-30
males have higher bp - until menopause then they are the same
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
carotid

32. Barely palpable
Feeble
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

33. right arm vs. left arm/ arm vs. leg BP?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
intermittent
^160/^100
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

34. How do drugs affect pulse?
Hyperthermia related to infection or excessive heat exposure
Radial
Feeble
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

35. When is apicial pulse used?
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.
12-20
Biot's respirations
fever

36. High BP
+1
16-20
hypertension
left Sims position

37. Inside ankle
Posterior tibial
arrhythmia
The pulse rate gradually diminishes from birth to adulthood
It increases to push the blood through more rigid pathways.

38. Bend of knee
low
Pedal pulse
bradypnea
popliteal

39. State of insufficient oxygen
hypoxia
Apical
Diaphoresis
Posterior tibial

40. Elevated temperature
in the alveoli - tiny thin-walled sacs
16-20
from drug therapy - a neurologic problem or dehydration.
fever

41. Head injury BP?
bradycardia
Conduction
raises BP.
systolic pressure indicated by faint - clear sound that gradually grow louder.

42. Weak and regular (even beats wit poor force)
+1
lysis
Nursing interventions to reduce fever
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.

43. Air movemtn causes heat to be transferred from the skin to the air molecules.
Biot's
16-20
from drug therapy - a neurologic problem or dehydration.
Convection

44. How does increased body temperature increase the pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Pedal pulse
low
120/80

45. Side of forehead
Cardiac Output
Systolic pressure
Pedal pulse
Temporal

46. Fast - deep respirations with abrupt pauses

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47. What are the 5 vital signs?
cardiac patients or patients who have had rectal surgery.
temperature - pulse - respiration - blood pressure - and pain level.
Conduction
Hypothermia

48. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
hypoxia
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.
Vascular resistance drops and the blood pressure decreases
Kussmaul's respiration

49. What happens to the blood if overhydration occurs?
males have higher bp - until menopause then they are the same
men - African Americans - under a lot of stress - obese
+3
Blood pressure increases because there is more volume of blood in the vascular system.

50. Why would patients experience orthostatic hypotenstion?
Korotkoff sounds Phase IV: Muffling
from drug therapy - a neurologic problem or dehydration.
pyrexia
tachycardia