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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
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1. How do drugs affect pulse?
uncooperative patient - children - combative patients - dementia
about 1 degree lower than oral temperatures
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

2. How does increased body temperature increase the pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
low
Convection
Biot's respirations

3. What pulse is checked to determine whether there is any blockage of circulation in the artery up to that point - especially in patients who have had cardiac catherization using the femoral artery for the insertion of the catheter or those who had sur
Pedal pulse
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.
uncooperative patient - children - combative patients - dementia
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.

4. Average blood pressure should be
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Korotkoff sounds Phase III: Knocking
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.
120/70

5. Low oxygen
hypoxia
+3
in the alveoli - tiny thin-walled sacs
left Sims position

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

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7. Groin area
It increases to push the blood through more rigid pathways.
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
Femoral
Respiration

8. Gradual return to a normal temperature
Pons and Medulla of the brainstem
apnea
uncooperative patient - children - combative patients - dementia
lysis

9. A normal - relaxed breathing pattern
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.
remittent
the rate - the rhythm - and volume
Eupnea

10. What happens when vasodilation occurs?
Vascular resistance drops and the blood pressure decreases
Korotkoff sounds
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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.

11. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
hypoxia
temperature - pulse - respiration - blood pressure - and pain level.

12. How does size affect pulse?
Increases as body tries to remove excess heat
Core Temperature
Tall - slender people mayy ave a slower pulse rate than short - stout persons
ausculatation

13. Feel
Korotkoff sounds Phase V: Silence
palpate
Diaphoresis
The emotions increase hormone secretion - and the body activities required for this increase heat production.

14. No pulse palpable or heard on ausculation
absent
crackles
Conduction
Respiration

15. Are infants blood pressure low or high?
the lungs
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Biot's
low

16. Weak and regular (even beats wit poor force)
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
+1
It increases to push the blood through more rigid pathways.
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.

17. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
crackles
30-80
dyspnea
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

18. Average pulse rate for an adult
30-80
Diastolic pressure
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
72 bpm

19. 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.
Crisis
12-20
It will also fall
hypoxemia

20. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
BMR
stridor
Conduction
Pulse

21. How is shock caused?
20-30
Sinoatrial node (SA NODE)
remittent
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

22. 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
120/70
remittent
Apical

23. Obtaining the correct size for a cuff for BP?
Pons and Medulla of the brainstem
Diastolic pressure
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

24. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
Respiration
30-80
Cheyenne-Stokes
the blood pressure will rise in order to push the blood along.

25. Absence of breathing
apnea
Diaphoresis
^160/^100
Tachypnea

26. Excessive sweat production
Diastolic pressure
Diaphoresis
ausculatation
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

27. How does disease increase the body's temperature?
absent
Vascular resistance drops and the blood pressure decreases
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
intermittent

28. Encourage a large fluid intake - lower room temperature - increase air circulation - remove items of clothes - control or reduce the amount of body activity - carry out physicians orders
Radial
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Nursing interventions to reduce fever
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

29. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Cardiac Output
Korotkoff sounds Phase IV: Muffling
Korotkoff sounds
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. Drop in blood pressure when arising to a standing position.
Rhonchi
orthostatic hypertension
oximetry
Korotkoff sounds Phase IV: Muffling

31. 2nd stage of fever is?
remittent
oximeter
Feeble
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.

32. Fast - deep respirations with abrupt pauses

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33. What characteristics should be noted when checking the pulse?
Stertor
3 in the right lung and 2 lobes in the left
Axillary.
the rate - the rhythm - and volume

34. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
72 bpm
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.
Cheyenne-Stokes
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

35. High BP
hypertension
Temporal
Stertor
Hyperthermia related to infection or excessive heat exposure

36. How does external respiration occur?
Respiration
left Sims position
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
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

37. Slow and shallow breathing - leads to hypoxemia.
hypertension
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
bradypnea
Posterior tibial

38. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Korotkoff sounds Phase IV: Muffling
from drug therapy - a neurologic problem or dehydration.
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.
low

39. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
72 bpm
arrhythmia
blood pressure is lowest in the morning. and higher in the afternoone
hyperoxia

40. The average temperature in the older adult
96.5 to 97.5
left Sims position
men - African Americans - under a lot of stress - obese
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.

41. 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.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Hypothermia
remittent
Nursing interventions to reduce fever

42. High oxygen
hyperoxia
Blood pressure increases because there is more volume of blood in the vascular system.
low
dyspnea

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
16-20
oximetry
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

44. 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.
oximeter
Radial
remittent
popliteal

45. When should rectal temperatures be used?
+3
Evaporation
It increases to push the blood through more rigid pathways.
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

46. Both strong and weak beats occur within 1 minute
tachycardia
Stroke Volume
Crisis
Irregular

47. Diurnal variation BP?
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
blood pressure is lowest in the morning. and higher in the afternoone
Diastolic pressure
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

48. Barely palpable
hypertension
blood pressure is lowest in the morning. and higher in the afternoone
Feeble
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

49. What patients should not use a glass thermometer orally?
Hyperventilation
uncooperative patient - children - combative patients - dementia
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Korotkoff sounds Phase II Swishing

50. 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.
absent
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
Temperature will remain below 102 degrees with use of hypothermia blanket

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Measuring Vital Signs

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