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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
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
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.
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
Core Temperature

2. Elderly respiration
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.
16-20
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Diastolic pressure

3. Newborn
the rate - the rhythm - and volume
30-80
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.
hyperoxia

4. What happens to the blood if overhydration occurs?
Blood pressure increases because there is more volume of blood in the vascular system.
thready
Radial
^160/^100

5. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Nursing interventions to reduce fever
Korotkoff sounds
Biot's
Feeble

6. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
orthostatic hypertension
Hypothermia
shallow or slow breathing
oximeter

7. Louder knocking sound that occurs wit each heartbeat
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
absent
Korotkoff sounds Phase III: Knocking
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

8. An example of a nursing diagnoses
constant
Hyperthermia related to infection or excessive heat exposure
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Systolic pressure

9. Does the respiration rate increase or decrease during fever?
Pulse
Increases as body tries to remove excess heat
Hypothermia
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

10. Air movemtn causes heat to be transferred from the skin to the air molecules.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Pulse pressure
Convection
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.

11. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
Hyperventilation
males have higher bp - until menopause then they are the same
Feeble
stridor

12. When warm skin touches a cool object - heat is lost to the object.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Conduction
hyperoxia
Tachypnea

13. Excessive sweat production
Vascular resistance drops and the blood pressure decreases
Eupnea
Diaphoresis
Evaporation

14. Side of neck
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
+3
carotid
from drug therapy - a neurologic problem or dehydration.

15. How do you measure the apical pulse?
Temperature will remain below 102 degrees with use of hypothermia blanket
Korotkoff sounds Phase V: Silence
96.5 to 97.5
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

16. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
blood pressure is lowest in the morning. and higher in the afternoone
wheeze
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Radial

17. 2nd stage of fever is?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
cardiac patients or patients who have had rectal surgery.
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.
Vascular resistance drops and the blood pressure decreases

18. 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
hyperoxia
+1
Hyperventilation
hypertension

19. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Vascular resistance drops and the blood pressure decreases
arrhythmia
fever
Respiration

20. Murmur or swishing sounds that increase as the cuff is deflated
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
^160/^100
constant
Korotkoff sounds Phase II Swishing

21. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Sinoatrial node (SA NODE)
Relapsing
Crisis
Hyperthermia related to infection or excessive heat exposure

22. High oxygen
Hypothermia
Korotkoff sounds Phase IV: Muffling
dyspnea
hyperoxia

23. When the heart contracts How many mLs of blood is propelled into the aorta?
+3
Kussmaul's respiration
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
60 to 70 mL

24. Hearing
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.
wheeze
Femoral
ausculatation

25. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
+3
constant
Rhonchi
pyrogens

26. No pulse palpable or heard on ausculation
absent
from drug therapy - a neurologic problem or dehydration.
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.
popliteal

27. Taking a rectal temperature
higher
thready
60 to 70 mL
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

28. What characteristics should be noted when checking the pulse?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
the rate - the rhythm - and volume
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
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.

29. How does age affect pulse?
palpate
The pulse rate gradually diminishes from birth to adulthood
shallow or slow breathing
+1

30. What happens when vasodilation occurs?
Feeble
Vascular resistance drops and the blood pressure decreases
Cheyenne-Stokes
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.

31. The maximum pressure exerted on the artery during left ventricular contraction.
Systolic pressure
Tall - slender people mayy ave a slower pulse rate than short - stout persons
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
96.5 to 97.5

32. Feel
Radial
palpate
Korotkoff sounds Phase IV: Muffling
72 bpm

33. Rectal temperature are
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.
Hypothermia
^160/^100
about 1 degree higher than oral temperatures

34. Korotkoff sounds Ausculatatory gap:
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
palpate
higher
hypertension

35. Sex BP?
apnea
males have higher bp - until menopause then they are the same
Pedal pulse
about 1 degree lower than oral temperatures

36. How is pulse best found?
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.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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

37. Bend of elbow
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.
+2
Brachial
stridor

38. Strong and regular ( even beats wit moderate force)
+2
^160/^100
Hyperthermia related to infection or excessive heat exposure
Blood pressure increases because there is more volume of blood in the vascular system.

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

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40. Both strong and weak beats occur within 1 minute
Irregular
Korotkoff sounds Phase II Swishing
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

41. 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.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
hypoxemia
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.
pyrogens

42. Full and bounding (even beats wit strong force)
Relapsing
+3
arrhythmia
Apical

43. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
Diaphoresis
oximeter
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 systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

44. 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
Rhonchi
absent
Pedal pulse
The emotions increase hormone secretion - and the body activities required for this increase heat production.

45. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
apnea
dyspnea
Pulse
left Sims position

46. right arm vs. left arm/ arm vs. leg BP?
Core Temperature
Brachial
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
+1

47. 3rd stage of fever?
crackles
Korotkoff sounds Phase III: Knocking
cardiac patients or patients who have had rectal surgery.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

48. How does physical exercise raise the body's temperature?
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Temperature will remain below 102 degrees with use of hypothermia blanket
120/70
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.

49. Measurement of oxygen
It increases to push the blood through more rigid pathways.
oximetry
constant
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

50. What affects does aging do to the heart rate?

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