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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. If the cardiac output falls what will happen to the BP?
It will also fall
Crisis
Korotkoff sounds Phase V: Silence
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

2. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
Biot's
the blood pressure will rise in order to push the blood along.
Nursing interventions to reduce fever
left Sims position

3. Side of neck
carotid
hypoxemia
Biot's
thready

4. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
palpate
about 1 degree higher than oral temperatures
Stroke volume

5. 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.
Increases as body tries to remove excess heat
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Stertor

6. What happens when vasodilation occurs?
It will also fall
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Kussmaul's respiration
Vascular resistance drops and the blood pressure decreases

7. When should rectal temperatures NOT be used?
Crisis
Biot's respirations
cardiac patients or patients who have had rectal surgery.
fever

8. Weak and regular (even beats wit poor force)
+1
Pulse pressure
thready
hypoxia

9. 3rd stage of fever?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
120/80
Hyperthermia related to infection or excessive heat exposure

10. 3 yr old
20-30
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.
Hyperventilation

11. Those at risk for hypothermia include
120-139/80-89
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.
Respiration
temperature - pulse - respiration - blood pressure - and pain level.

12. 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.
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
crackles
Cheyenne-Stokes
ausculatation

13. 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.
bradypnea
120/70
20-30

14. 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
Posterior tibial
Nursing interventions to reduce fever
Apical
72 bpm

15. The temperature of the deep tissues of the body
low BP
^160/^100
Pulse
Core Temperature

16. What happens to the blood if overhydration occurs?
Blood pressure increases because there is more volume of blood in the vascular system.
remittent
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
raises BP.

17. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
Hypothermia
Temporal
It increases to push the blood through more rigid pathways.
orthostatic hypertension

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

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19. Weak and may be irregular
thready
Kussmaul's respiration
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.
Pedal pulse

20. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
72 bpm
Korotkoff sounds Phase III: Knocking
16-20
low BP

21. Stress & emotions. BP?
+2
shallow or slow breathing
higher
Tall - slender people mayy ave a slower pulse rate than short - stout persons

22. Korotkoff sounds Phase I: Tapping
systolic pressure indicated by faint - clear sound that gradually grow louder.
The pulse rate gradually diminishes from birth to adulthood
Blood pressure increases because there is more volume of blood in the vascular system.
remittent

23. Gradual return to a normal temperature
lysis
low
Brachial
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

24. How is shock caused?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
bradypnea

25. BP at or lower 90/60.
Stroke Volume
wheeze
Korotkoff sounds Phase V: Silence
hypotension

26. Newborn
Hyperthermia related to infection or excessive heat exposure
low BP
thready
30-80

27. 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.
Convection
Cheyenne-Stokes
fever

28. Fever above 100.2 F
97.5 to 99.5
Korotkoff sounds Phase V: Silence
pyrexia
carotid

29. Diurnal variation BP?
Stertor
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
blood pressure is lowest in the morning. and higher in the afternoone
Kussmaul's respiration

30. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Pulse
Vascular resistance drops and the blood pressure decreases
Axillary.
Respiration

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

32. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
orthostatic hypertension
97.5 to 99.5
Systolic pressure
Respiration

33. Signs and symptoms of shock
Temporal
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Radial
hypoxia

34. Symptoms of hypoxia
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
the rate - the rhythm - and volume
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
men - African Americans - under a lot of stress - obese

35. How do drugs affect pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Posterior tibial
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Convection

36. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
pyrogens
oximeter
Pons and Medulla of the brainstem
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. How does menstrual cycle and pregnancy raise the body's temperature?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Korotkoff sounds Phase III: Knocking
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Radial

38. An example of nursing planning
Radial
Hyperthermia related to infection or excessive heat exposure
Temperature will remain below 102 degrees with use of hypothermia blanket
72 bpm

39. Pulse lower than 60 beats per minute
bradycardia
Axillary.
30-80
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

40. State of insufficient oxygen
hypoxia
140-159/90-99
Relapsing
+2

41. 1st stage of fever is?
orthostatic hypertension
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
thready
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

42. Why would patients experience orthostatic hypotenstion?
30-80
96.5 to 97.5
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
from drug therapy - a neurologic problem or dehydration.

43. Gas exchange in the blood occurs where?
shallow or slow breathing
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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
in the alveoli - tiny thin-walled sacs

44. Drop in blood pressure when arising to a standing position.
temperature - pulse - respiration - blood pressure - and pain level.
Cardiac Output
Tall - slender people mayy ave a slower pulse rate than short - stout persons
orthostatic hypertension

45. Decreased levels of oxygen in the blood - often seen in patients wo are under medical sedation - who are recovering from anesthesia or abdominal surgery - or who are in a weak or debiliated condition.
hypoxemia
pyrogens
Dorsalis pedis
fever

46. The maximum pressure exerted on the artery during left ventricular contraction.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
temperature - pulse - respiration - blood pressure - and pain level.
lysis
Systolic pressure

47. 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?
Conduction
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
the lungs
stridor

48. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
Korotkoff sounds Phase IV: Muffling
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Irregular
orthostatic hypertension

49. How is pulse best found?
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.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
^160/^100
bradypnea

50. Breathing is an involuntary automatic function controlled by the respiratory center located where?
blood pressure is lowest in the morning. and higher in the afternoone
Pons and Medulla of the brainstem
constant
cardiac patients or patients who have had rectal surgery.

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Measuring Vital Signs

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