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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. What characteristics should be noted when checking the pulse?
the rate - the rhythm - and volume
oximeter
Stroke Volume
uncooperative patient - children - combative patients - dementia

2. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
Kussmaul's respiration
It increases to push the blood through more rigid pathways.
dyspnea
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

3. Abrupt decline in fever
Nursing interventions to reduce fever
Crisis
72 bpm
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

4. 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.
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.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
crackles

5. What affects does aging do to the blood pressure?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
16-20
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

6. Risk for prolonged hypertension
Hyperventilation
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
popliteal
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

7. 3 yr old
97.5 to 99.5
in the alveoli - tiny thin-walled sacs
20-30
Korotkoff sounds Phase V: Silence

8. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
97.5 to 99.5
3 in the right lung and 2 lobes in the left
oximeter
Relapsing

9. Lobes in the lungs?
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Biot's respirations
3 in the right lung and 2 lobes in the left
Diaphoresis

10. Gradual return to a normal temperature
Irregular
lysis
hypoxia
Femoral

11. Does the respiration rate increase or decrease during fever?
Increases as body tries to remove excess heat
Pedal pulse
Kussmaul's respiration
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

12. If the cardiac output falls what will happen to the BP?
orthostatic hypertension
It will also fall
hypoxia
fever

13. Hearing
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
ausculatation
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.
60 to 70 mL

14. 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
apnea
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.
hypotension

15. What patients should not use a glass thermometer orally?
120-139/80-89
The pulse rate gradually diminishes from birth to adulthood
Brachial
uncooperative patient - children - combative patients - dementia

16. How does physical exercise raise the body's temperature?
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.
Dorsalis pedis
the lungs
72 bpm

17. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Dorsalis pedis
wheeze
Conduction
Pulse

18. Stage 1 hypertension
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
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.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
140-159/90-99

19. Weak and regular (even beats wit poor force)
Biot's
+1
16-20
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

20. 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.
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.
Core Temperature
Radial
remittent

21. How do emotions increase the pulse rate?
Posterior tibial
It will also fall
Kussmaul's respiration
Acute anxiety stimulate the nervous system - raising the pulse.

22. 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.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Temporal
in the alveoli - tiny thin-walled sacs

23. Groin area
Temperature will remain below 102 degrees with use of hypothermia blanket
Femoral
Korotkoff sounds Phase IV: Muffling
the lungs

24. Average pulse rate for an adult
higher
Irregular
hypoxia
72 bpm

25. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
Femoral
oximeter
orthostatic hypertension
low BP

26. 3rd stage of fever?
bradycardia
Diastolic pressure
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

27. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
constant
bradypnea
20-30
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

28. Side of neck
120/70
fever
raises BP.
carotid

29. Gas exchange in the blood occurs where?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
72 bpm
Feeble
in the alveoli - tiny thin-walled sacs

30. When is apicial pulse used?
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.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
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
BMR

31. Heart
20-30
Apical
hyperoxia
Evaporation

32. How should baby's temperature be taken?
Axillary.
constant
remittent
crackles

33. The maximum pressure exerted on the artery during left ventricular contraction.
men - African Americans - under a lot of stress - obese
96.5 to 97.5
Systolic pressure
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

34. Signs and symptoms of shock
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.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
intermittent
Biot's

35. 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.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Dorsalis pedis
carotid

36. Obtaining the correct size for a cuff for BP?
Feeble
^160/^100
60 to 70 mL
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

37. Side of forehead
hyperoxia
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.
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.
Temporal

38. High oxygen
hyperoxia
shallow or slow breathing
Axillary.
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.

39. When should rectal temperatures be used?
shallow or slow breathing
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
hypoxia
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

40. Slow and shallow breathing - leads to hypoxemia.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
bradypnea
cardiac patients or patients who have had rectal surgery.
Cardiac Output

41. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
the blood pressure will rise in order to push the blood along.
Tachypnea
orthostatic hypertension
remittent

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

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43. Side of wrist
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.
hypotension
Radial

44. 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
96.5 to 97.5
palpate
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

45. Whats the best position to take a rectal temperature?
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
It increases to push the blood through more rigid pathways.
left Sims position
bradycardia

46. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
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
Tachypnea
arrhythmia
Cheyenne-Stokes

47. 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.
+2
remittent
16-20
Hypothermia

48. Blood pressure for any adult should be no higher than
120/70
left Sims position
Kussmaul's respiration
120/80

49. High BP
hypertension
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
Eupnea
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.

50. An example of nursing planning
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Temperature will remain below 102 degrees with use of hypothermia blanket
The pulse rate gradually diminishes from birth to adulthood
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.