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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.
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. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
constant
the rate - the rhythm - and volume
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
Pons and Medulla of the brainstem

2. What happens to the blood if overhydration occurs?
Eupnea
Blood pressure increases because there is more volume of blood in the vascular system.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
120/80

3. By measuring the blood pressure you obtain vital info about what?
Sinoatrial node (SA NODE)
Radial
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
constant

4. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Evaporation
120/70
Temporal
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.

5. Heart
low BP
Apical
Korotkoff sounds Phase III: Knocking
uncooperative patient - children - combative patients - dementia

6. 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?
Eupnea
intermittent
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Apical

7. Average pulse rate for an adult
men - African Americans - under a lot of stress - obese
140-159/90-99
72 bpm
Posterior tibial

8. What affects does aging do to the respiratory rate?
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
Increases as body tries to remove excess heat
in the alveoli - tiny thin-walled sacs
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

9. Gas exchange in the blood occurs where?
in the alveoli - tiny thin-walled sacs
temperature - pulse - respiration - blood pressure - and pain level.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
arrhythmia

10. What patients should not use a glass thermometer orally?
Posterior tibial
140-159/90-99
uncooperative patient - children - combative patients - dementia
crackles

11. The temperature falls to normal and then rises again in a repeating pattern.
wheeze
hyperoxia
72 bpm
Relapsing

12. How does emotional stress raise the body's temperature?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Diastolic pressure
Cheyenne-Stokes
Irregular

13. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
popliteal
Cardiac Output
intermittent
Rhonchi

14. Low oxygen
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
popliteal
oximetry
hypoxia

15. Rectal temperature are
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Increases as body tries to remove excess heat
about 1 degree higher than oral temperatures
hyperoxia

16. Obtaining the correct size for a cuff for BP?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
wheeze
hypoxia

17. Newborn
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.
30-80
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Korotkoff sounds

18. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
16-20
3 in the right lung and 2 lobes in the left
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
arrhythmia

19. 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.
30-80
Tachypnea
Convection
intermittent

20. Bend of knee
3 in the right lung and 2 lobes in the left
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
higher
popliteal

21. 3rd stage of fever?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Crisis
Rhonchi
about 1 degree lower than oral temperatures

22. Enviromental temperature BP?
popliteal
pyrogens
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
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.

23. Side of neck
raises BP.
carotid
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
palpate

24. Average blood pressure should be
Temporal
about 1 degree higher than oral temperatures
about 1 degree lower than oral temperatures
120/70

25. 3 yr old
Temperature will remain below 102 degrees with use of hypothermia blanket
20-30
males have higher bp - until menopause then they are the same
Hyperventilation

26. The temperature of the deep tissues of the body
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.
Dorsalis pedis
Core Temperature
the lungs

27. High oxygen
Hypothermia
hyperoxia
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
30-80

28. 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
about 1 degree lower than oral temperatures
Posterior tibial
16-20

29. What happens when vasodilation occurs?
+3
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Nursing interventions to reduce fever
Vascular resistance drops and the blood pressure decreases

30. Diurnal variation BP?
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
Temporal
Korotkoff sounds Phase V: Silence

31. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
pyrogens
Convection
Diastolic pressure
Crisis

32. Korotkoff sounds Phase I: Tapping
males have higher bp - until menopause then they are the same
systolic pressure indicated by faint - clear sound that gradually grow louder.
oximeter
Nursing interventions to reduce fever

33. Why would patients experience orthostatic hypotenstion?
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.
from drug therapy - a neurologic problem or dehydration.
uncooperative patient - children - combative patients - dementia
blood pressure is lowest in the morning. and higher in the afternoone

34. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
shallow or slow breathing
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
the blood pressure will rise in order to push the blood along.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

35. 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.
Pons and Medulla of the brainstem
Cardiac Output
Stroke volume
hypoxia

36. This affects the character of the pulse.
carotid
Apical
Stroke Volume
palpate

37. How does increased body temperature increase the pulse?
Femoral
the blood pressure will rise in order to push the blood along.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
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.

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

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39. When should rectal temperatures NOT be used?
remittent
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
12-20
cardiac patients or patients who have had rectal surgery.

40. 2nd stage of fever is?
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.
Korotkoff sounds
+2
Respiration

41. Elevated temperature
fever
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Posterior tibial
lysis

42. Increased rate and depth with panting and long grunting exhalation. Often seen with patients with acidosis and renal failure.

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43. How does external respiration occur?
left Sims position
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
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

44. Air movemtn causes heat to be transferred from the skin to the air molecules.
Convection
Posterior tibial
BMR
about 1 degree lower than oral temperatures

45. Adolescent
It increases to push the blood through more rigid pathways.
16-20
absent
oximeter

46. 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
the rate - the rhythm - and volume
Korotkoff sounds
Cardiac Output

47. Side of forehead
^160/^100
Temporal
left Sims position
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.

48. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Kussmaul's respiration
oximeter
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Korotkoff sounds Phase IV: Muffling

49. Disappearance of sound. (marks diastolic pressure in adults)
60 to 70 mL
12-20
Femoral
Korotkoff sounds Phase V: Silence

50. Pulse lower than 60 beats per minute
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.
bradycardia
thready
systolic pressure indicated by faint - clear sound that gradually grow louder.