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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. How does disease increase the body's temperature?
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
97.5 to 99.5
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
Crisis

2. 1st stage of fever is?
hypoxia
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
The emotions increase hormone secretion - and the body activities required for this increase heat production.
BMR

3. 2nd stage of fever is?
Axillary.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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.
left Sims position

4. State of insufficient oxygen
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.
Stroke Volume
hypoxia
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. Louder knocking sound that occurs wit each heartbeat
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
Pedal pulse
Korotkoff sounds Phase III: Knocking
+3

6. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
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.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Evaporation
^160/^100

7. Korotkoff sounds Ausculatatory gap:
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.
uncooperative patient - children - combative patients - dementia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
left Sims position

8. Absence of breathing
apnea
Tall - slender people mayy ave a slower pulse rate than short - stout persons
low BP
72 bpm

9. When is apicial pulse used?
pyrogens
16-20
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.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

10. How cardiac contractions are normally initiated by the electrical impules emerging from what?
fever
Pulse
orthostatic hypertension
Sinoatrial node (SA NODE)

11. Axillary temperature are
Stroke volume
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.
left Sims position
about 1 degree lower than oral temperatures

12. No pulse palpable or heard on ausculation
Blood pressure increases because there is more volume of blood in the vascular system.
Korotkoff sounds Phase II Swishing
absent
tachycardia

13. Weak and may be irregular
Axillary.
low BP
Blood pressure increases because there is more volume of blood in the vascular system.
thready

14. How should respirations be counted?
30-80
Pulse
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Tachypnea

15. This affects the character of the pulse.
low BP
carotid
Stroke Volume
Increases as body tries to remove excess heat

16. Taking a rectal temperature
bradypnea
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
about 1 degree higher than oral temperatures
from drug therapy - a neurologic problem or dehydration.

17. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Cheyenne-Stokes
hypoxemia
96.5 to 97.5
Rhonchi

18. When should rectal temperatures be used?
Biot's
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
Stroke volume
Pulse

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

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20. Elderly respiration
from drug therapy - a neurologic problem or dehydration.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
BMR
16-20

21. The maximum pressure exerted on the artery during left ventricular contraction.
Systolic pressure
Temperature will remain below 102 degrees with use of hypothermia blanket
120-139/80-89
Hypothermia

22. Both strong and weak beats occur within 1 minute
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Nursing interventions to reduce fever
Irregular
hypotension

23. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
72 bpm
shallow or slow breathing
absent
oximeter

24. 3rd stage of fever?
Systolic pressure
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
the rate - the rhythm - and volume

25. Average pulse rate for an adult
16-20
72 bpm
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.
Nursing interventions to reduce fever

26. 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
tachycardia
Brachial
hypoxia

27. The temperature falls to normal and then rises again in a repeating pattern.
uncooperative patient - children - combative patients - dementia
Dorsalis pedis
Relapsing
hypoxia

28. If the cardiac output falls what will happen to the BP?
Stroke Volume
Blood pressure increases because there is more volume of blood in the vascular system.
It will also fall
BMR

29. The rate at which heat is produced when the body is at rest.
carotid
Biot's respirations
Temporal
BMR

30. Side of forehead
Temporal
Increases as body tries to remove excess heat
higher
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.

31. Blood pressure for any adult should be no higher than
from drug therapy - a neurologic problem or dehydration.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
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.
120/80

32. What patients should not use a glass thermometer orally?
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
uncooperative patient - children - combative patients - dementia
the rate - the rhythm - and volume

33. 3 yr old
Cheyenne-Stokes
20-30
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
3 in the right lung and 2 lobes in the left

34. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
Systolic pressure
dyspnea
Nursing interventions to reduce fever
ausculatation

35. How does menstrual cycle and pregnancy raise the body's temperature?
Feeble
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Pedal pulse
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

36. Does the respiration rate increase or decrease during fever?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
uncooperative patient - children - combative patients - dementia
hypertension
Increases as body tries to remove excess heat

37. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
^160/^100
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
remittent
Respiration

38. Bend of elbow
shallow or slow breathing
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.
Brachial
about 1 degree lower than oral temperatures

39. 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.
constant
Crisis
Relapsing
Tachypnea

40. Disappearance of sound. (marks diastolic pressure in adults)
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Korotkoff sounds Phase V: Silence
oximeter
It increases to push the blood through more rigid pathways.

41. The temperature of the deep tissues of the body
Core Temperature
tachycardia
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.
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.

42. Abrupt decline in fever
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
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.
Crisis
low BP

43. 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
Korotkoff sounds Phase III: Knocking
pyrexia
Hyperventilation
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

44. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
hypertension
hypoxia
Hyperthermia related to infection or excessive heat exposure

45. Low oxygen
Axillary.
Systolic pressure
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
hypoxia

46. Diurnal variation BP?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
blood pressure is lowest in the morning. and higher in the afternoone
dyspnea
Axillary.

47. 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.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
hypertension
hypoxia

48. The volume of blood pushed into the aorta per heartbeat.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
temperature - pulse - respiration - blood pressure - and pain level.
Stroke volume
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.

49. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
hyperoxia
Pulse
low BP

50. An example of nursing planning
140-159/90-99
cardiac patients or patients who have had rectal surgery.
Temperature will remain below 102 degrees with use of hypothermia blanket
Pulse pressure