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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. 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
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Posterior tibial
12-20

2. Healthly adult
It will also fall
constant
12-20
It increases to push the blood through more rigid pathways.

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

4. Absence of breathing
thready
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
apnea
dyspnea

5. Taking axillary temperature
+2
palpate
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.
Blood pressure increases because there is more volume of blood in the vascular system.

6. Both strong and weak beats occur within 1 minute
pyrexia
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Irregular

7. 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.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Cardiac Output

8. What patients should not use a glass thermometer orally?
wheeze
remittent
uncooperative patient - children - combative patients - dementia
Nursing interventions to reduce fever

9. Whats the best position to take a rectal temperature?
the lungs
from drug therapy - a neurologic problem or dehydration.
bradypnea
left Sims position

10. Subnormal body temperature the regulating center in the hypothalamus is greatly impaired when the temperature of the body falls below 94 degrees - at that point? sleepiness and coma are apt to develop.
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
Hypothermia
hyperoxia
96.5 to 97.5

11. How is shock caused?
Core Temperature
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

12. By measuring the blood pressure you obtain vital info about what?
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
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Nursing interventions to reduce fever
Stroke volume

13. 3rd stage of fever?
from drug therapy - a neurologic problem or dehydration.
Axillary.
Nursing interventions to reduce fever
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

14. What affects does aging do to the blood pressure?
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.
Dorsalis pedis
Stroke Volume

15. High BP
Apical
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
hypertension
Sinoatrial node (SA NODE)

16. Obtaining the correct size for a cuff for BP?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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
the blood pressure will rise in order to push the blood along.
+1

17. Lobes in the lungs?
3 in the right lung and 2 lobes in the left
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
carotid
97.5 to 99.5

18. The maximum pressure exerted on the artery during left ventricular contraction.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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.
pyrexia
Systolic pressure

19. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
in the alveoli - tiny thin-walled sacs
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Cheyenne-Stokes
Axillary.

20. High oxygen
hyperoxia
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
hypertension
about 1 degree lower than oral temperatures

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

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22. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
Pons and Medulla of the brainstem
Pulse
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
It increases to push the blood through more rigid pathways.

23. An example of a nursing diagnoses
pyrogens
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Hyperthermia related to infection or excessive heat exposure
carotid

24. 3 yr old
Korotkoff sounds Phase IV: Muffling
20-30
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
16-20

25. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
Relapsing
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
dyspnea
hypoxemia

26. What happens when vasodilation occurs?
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.
Vascular resistance drops and the blood pressure decreases
Axillary.
Dorsalis pedis

27. A normal - relaxed breathing pattern
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Irregular
Eupnea
Tachypnea

28. Measurement of oxygen
oximetry
bradypnea
ausculatation
Pons and Medulla of the brainstem

29. How do you measure the apical pulse?
cardiac patients or patients who have had rectal surgery.
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
It will also fall
120-139/80-89

30. Does the respiration rate increase or decrease during fever?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Temperature will remain below 102 degrees with use of hypothermia blanket
hypoxemia
Increases as body tries to remove excess heat

31. Why would patients experience orthostatic hypotenstion?
120/70
males have higher bp - until menopause then they are the same
from drug therapy - a neurologic problem or dehydration.
It increases to push the blood through more rigid pathways.

32. Murmur or swishing sounds that increase as the cuff is deflated
Korotkoff sounds Phase II Swishing
in the alveoli - tiny thin-walled sacs
Systolic pressure
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

33. Excessive sweat production
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
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.
12-20
Diaphoresis

34. Korotkoff sounds Ausculatatory gap:
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
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.
Korotkoff sounds Phase II Swishing
+2

35. Air movemtn causes heat to be transferred from the skin to the air molecules.
Convection
oximetry
pyrogens
Crisis

36. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Pulse
oximetry
the rate - the rhythm - and volume
shallow or slow breathing

37. Gradual return to a normal temperature
30-80
lysis
pyrogens
20-30

38. Prehypertension
20-30
120-139/80-89
+2
Diastolic pressure

39. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
apnea
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.
Evaporation
The emotions increase hormone secretion - and the body activities required for this increase heat production.

40. Korotkoff sounds Phase I: Tapping
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Diastolic pressure
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.
systolic pressure indicated by faint - clear sound that gradually grow louder.

41. What characteristics should be noted when checking the pulse?
Hypothermia
Korotkoff sounds Phase V: Silence
Pons and Medulla of the brainstem
the rate - the rhythm - and volume

42. Signs and symptoms of shock
hypertension
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.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

43. 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.
Tachypnea
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
temperature - pulse - respiration - blood pressure - and pain level.
Nursing interventions to reduce fever

44. Feel
palpate
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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
about 1 degree higher than oral temperatures

45. What should you do if you cannot determine BP by ausculation?
120/80
Eupnea
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.
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.

46. Weak and regular (even beats wit poor force)
the rate - the rhythm - and volume
+1
Biot's
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

47. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
raises BP.
Korotkoff sounds Phase IV: Muffling
BMR
hypotension

48. Heart
It will also fall
Apical
12-20
Stertor

49. Full and bounding (even beats wit strong force)
Kussmaul's respiration
tachycardia
+3
Eupnea

50. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
crackles
arrhythmia
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
120/80