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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

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. Those at risk for hypothermia include
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.
Stroke Volume
left Sims position
97.5 to 99.5

2. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Korotkoff sounds
crackles
Cheyenne-Stokes
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

3. Full and bounding (even beats wit strong force)
+3
hypoxia
Posterior tibial
orthostatic hypertension

4. An example of a nursing diagnoses
oximeter
Hyperthermia related to infection or excessive heat exposure
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.
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

5. How do you measure the apical pulse?
carotid
Diastolic pressure
blood pressure is lowest in the morning. and higher in the afternoone
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

6. Rectal temperature are
low BP
about 1 degree higher than oral temperatures
Korotkoff sounds Phase V: Silence
arrhythmia

7. Breathing is an involuntary automatic function controlled by the respiratory center located where?
intermittent
pyrogens
Pons and Medulla of the brainstem
cardiac patients or patients who have had rectal surgery.

8. How is pulse best found?
Femoral
Conduction
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. How does emotional stress raise the body's temperature?
Radial
fever
72 bpm
The emotions increase hormone secretion - and the body activities required for this increase heat production.

10. Abrupt decline in fever
ausculatation
the blood pressure will rise in order to push the blood along.
Feeble
Crisis

11. Low oxygen
apnea
+2
hypoxia
from drug therapy - a neurologic problem or dehydration.

12. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
Core Temperature
+2
96.5 to 97.5

13. Sex BP?
males have higher bp - until menopause then they are the same
Stertor
Cheyenne-Stokes
Pedal pulse

14. Slow and shallow breathing - leads to hypoxemia.
Irregular
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
fever
bradypnea

15. Are infants blood pressure low or high?
raises BP.
Eupnea
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.
low

16. Healthly adult
cardiac patients or patients who have had rectal surgery.
12-20
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
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.

17. Increased or rapid breathing results from te presence of fever and a number or diseases. breathing rate increased about 4 breaths for each degree increase in 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.
wheeze
crackles
Tachypnea

18. 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?
Temporal
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
uncooperative patient - children - combative patients - dementia
Diaphoresis

19. No pulse palpable or heard on ausculation
Stroke Volume
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.
cardiac patients or patients who have had rectal surgery.
absent

20. What pulse is checked to determine whether there is any blockage of circulation in the artery up to that point - especially in patients who have had cardiac catherization using the femoral artery for the insertion of the catheter or those who had sur
Pedal pulse
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Conduction
apnea

21. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
uncooperative patient - children - combative patients - dementia
constant
Nursing interventions to reduce fever
Biot's

22. 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.
Conduction
hypoxemia
Kussmaul's respiration
Brachial

23. How does menstrual cycle and pregnancy raise the body's temperature?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Evaporation
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

24. 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.
Vascular resistance drops and the blood pressure decreases
120-139/80-89
Tachypnea
crackles

25. Fever above 100.2 F
Hyperventilation
pyrexia
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
lysis

26. 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.
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.
120/70

27. Average pulse rate for an adult
low
72 bpm
Diaphoresis
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

28. 2nd stage of fever is?
120-139/80-89
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.
Stertor
fever

29. Weak and may be irregular
Kussmaul's respiration
thready
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Posterior tibial

30. Feel
Nursing interventions to reduce fever
palpate
120-139/80-89
Korotkoff sounds Phase II Swishing

31. How should respirations be counted?
12-20
Apical
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
hypoxia

32. How does increased body temperature increase the pulse?
hypoxia
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

33. 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.
16-20
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.
Cardiac Output
Stertor

34. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
dyspnea
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

35. Axillary temperature are
about 1 degree lower than oral temperatures
16-20
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
hypoxia

36. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
Convection
Vascular resistance drops and the blood pressure decreases
It increases to push the blood through more rigid pathways.
+1

37. What happens to the blood if overhydration occurs?
Evaporation
The pulse rate gradually diminishes from birth to adulthood
Blood pressure increases because there is more volume of blood in the vascular system.
higher

38. When should rectal temperatures be used?
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.
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 III: Knocking
uncooperative patient - children - combative patients - dementia

39. 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
Dorsalis pedis
stridor
Nursing interventions to reduce fever
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

40. Gas exchange in the blood occurs where?
Stroke Volume
low
the blood pressure will rise in order to push the blood along.
in the alveoli - tiny thin-walled sacs

41. How do emotions increase the pulse rate?
Korotkoff sounds Phase V: Silence
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Convection
Acute anxiety stimulate the nervous system - raising the pulse.

42. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Brachial
oximetry
about 1 degree lower than oral temperatures
Rhonchi

43. The temperature falls to normal and then rises again in a repeating pattern.
cardiac patients or patients who have had rectal surgery.
120/70
Relapsing
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.

44. Stress & emotions. BP?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
popliteal
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
higher

45. A normal - relaxed breathing pattern
Eupnea
dyspnea
Korotkoff sounds Phase V: Silence
It will also fall

46. The average temperature in the older adult
96.5 to 97.5
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
orthostatic hypertension
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

47. An example of nursing planning
120-139/80-89
Temperature will remain below 102 degrees with use of hypothermia blanket
Stroke Volume
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.

48. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
blood pressure is lowest in the morning. and higher in the afternoone
arrhythmia
Dorsalis pedis
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

49. What should you do if you cannot determine BP by ausculation?
Hypothermia
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.
^160/^100
Systolic pressure

50. Taking axillary temperature
Systolic pressure
from drug therapy - a neurologic problem or dehydration.
^160/^100
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.