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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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1. How do drugs affect pulse?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Relapsing

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

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3. By measuring the blood pressure you obtain vital info about what?
20-30
hypoxia
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
arrhythmia

4. What should you do if you cannot determine BP by ausculation?
Radial
Diastolic pressure
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 palpation method is used. put cuff over arm - feel the radial point to get the systolic pressure you cant get the diastolic this way.

5. Adolescent
about 1 degree lower than oral temperatures
16-20
crackles
Axillary.

6. How is shock caused?
Hyperventilation
hypoxemia
Biot's
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

7. How does disease increase the body's temperature?
Stroke volume
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Temperature will remain below 102 degrees with use of hypothermia blanket
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

8. How is pulse best found?
Evaporation
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.
palpate
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

9. Alternating rise and fall of the temperature.
lysis
crackles
intermittent
the blood pressure will rise in order to push the blood along.

10. An example of a nursing diagnoses
96.5 to 97.5
Hyperthermia related to infection or excessive heat exposure
temperature - pulse - respiration - blood pressure - and pain level.
hyperoxia

11. When warm skin touches a cool object - heat is lost to the object.
Conduction
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.
Respiration
Pons and Medulla of the brainstem

12. Air movemtn causes heat to be transferred from the skin to the air molecules.
Core Temperature
Convection
Biot's
pyrexia

13. The rate at which heat is produced when the body is at rest.
BMR
3 in the right lung and 2 lobes in the left
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

14. 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.
96.5 to 97.5
arrhythmia
72 bpm

15. 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.
Hypothermia
Hyperventilation
Tachypnea
Increases as body tries to remove excess heat

16. High oxygen
hyperoxia
16-20
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.
Temporal

17. The volume of blood pushed into the aorta per heartbeat.
16-20
Stroke volume
carotid
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

18. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
Irregular
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
97.5 to 99.5

19. Strong and regular ( even beats wit moderate force)
Relapsing
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
shallow or slow breathing
+2

20. Sex BP?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Hyperventilation
Temperature will remain below 102 degrees with use of hypothermia blanket
males have higher bp - until menopause then they are the same

21. How does external respiration occur?
oximeter
3 in the right lung and 2 lobes in the left
Hyperventilation
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

22. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
oximeter
30-80
Dorsalis pedis
Korotkoff sounds

23. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
apnea
Korotkoff sounds Phase II Swishing
Diastolic pressure
palpate

24. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Korotkoff sounds
Feeble
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
Evaporation

25. How should respirations be counted?
16-20
bradypnea
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
3 in the right lung and 2 lobes in the left

26. 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.
low BP
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Tachypnea
hypoxemia

27. Average blood pressure should be
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
shallow or slow breathing
Temperature will remain below 102 degrees with use of hypothermia blanket
120/70

28. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
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.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Posterior tibial
shallow or slow breathing

29. How should baby's temperature be taken?
Axillary.
Apical
about 1 degree higher than oral temperatures
the blood pressure will rise in order to push the blood along.

30. How does increased body temperature increase the pulse?
thready
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
blood pressure is lowest in the morning. and higher in the afternoone
+1

31. Bend of elbow
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
ausculatation
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
Brachial

32. What happens when vasodilation occurs?
Respiration
Eupnea
Vascular resistance drops and the blood pressure decreases
Korotkoff sounds Phase II Swishing

33. Weak and may be irregular
Posterior tibial
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.
oximeter
thready

34. What affects does aging do to the respiratory rate?
Stroke Volume
hypoxia
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
120-139/80-89

35. BP at or lower 90/60.
Cardiac Output
hypotension
Kussmaul's respiration
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.

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

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37. Obtaining the correct size for a cuff for BP?
hypoxia
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Nursing interventions to reduce fever
Feeble

38. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Temporal
left Sims position
low
Sinoatrial node (SA NODE)

39. What happens to the blood if overhydration occurs?
the lungs
Blood pressure increases because there is more volume of blood in the vascular system.
low BP
Temperature will remain below 102 degrees with use of hypothermia blanket

40. How does emotional stress raise the body's temperature?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Pulse pressure
Korotkoff sounds Phase III: Knocking
Hyperthermia related to infection or excessive heat exposure

41. Diurnal variation BP?
blood pressure is lowest in the morning. and higher in the afternoone
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.
Crisis
60 to 70 mL

42. Blood pressure for any adult should be no higher than
120/80
Hypothermia
Relapsing
The pulse rate gradually diminishes from birth to adulthood

43. 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.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
temperature - pulse - respiration - blood pressure - and pain level.

44. Barely palpable
Feeble
Hypothermia
Conduction
in the alveoli - tiny thin-walled sacs

45. 1st stage of fever is?
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
Pulse
oximeter
Korotkoff sounds Phase II Swishing

46. 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.
raises BP.
hypertension
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
crackles

47. Gradual return to a normal temperature
hypoxia
pyrogens
lysis
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

48. right arm vs. left arm/ arm vs. leg BP?
pyrogens
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
cardiac patients or patients who have had rectal surgery.
Systolic pressure

49. What characteristics should be noted when checking the pulse?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
oximeter
oximetry
the rate - the rhythm - and volume

50. Axillary temperature are
constant
about 1 degree lower than oral temperatures
shallow or slow breathing
120-139/80-89

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Measuring Vital Signs

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