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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 external respiration occur?
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
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
Korotkoff sounds
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

2. How do you measure the apical pulse?
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
Systolic pressure
Pons and Medulla of the brainstem
hypertension

3. 3 yr old
Stertor
pyrexia
20-30
Korotkoff sounds Phase V: Silence

4. Side of wrist
30-80
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Radial
Korotkoff sounds Phase IV: Muffling

5. How is pulse best found?
oximeter
It increases to push the blood through more rigid pathways.
Stertor
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.

6. What affects does aging do to the respiratory rate?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Systolic pressure

7. Elevated temperature
higher
Korotkoff sounds Phase V: Silence
fever
oximetry

8. Why would patients experience orthostatic hypotenstion?
Axillary.
30-80
Acute anxiety stimulate the nervous system - raising the pulse.
from drug therapy - a neurologic problem or dehydration.

9. The volume of blood pushed into the aorta per heartbeat.
Korotkoff sounds Phase II Swishing
palpate
Brachial
Stroke volume

10. Taking axillary 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.
Temporal
low
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.

11. The average temperature in the older adult
hypoxia
Radial
96.5 to 97.5
pyrexia

12. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Systolic pressure
Korotkoff sounds

13. Korotkoff sounds Phase I: Tapping
+1
Rhonchi
systolic pressure indicated by faint - clear sound that gradually grow louder.
Blood pressure increases because there is more volume of blood in the vascular system.

14. Inside ankle
It will also fall
Posterior tibial
Korotkoff sounds Phase III: Knocking
Acute anxiety stimulate the nervous system - raising the pulse.

15. 1st stage of fever is?
+1
The emotions increase hormone secretion - and the body activities required for this increase heat production.
the rate - the rhythm - and volume
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

16. Does the respiration rate increase or decrease during fever?
Increases as body tries to remove excess heat
120/80
the rate - the rhythm - and volume
3 in the right lung and 2 lobes in the left

17. Sex BP?
males have higher bp - until menopause then they are the same
raises BP.
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.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

18. Obtaining the correct size for a cuff for BP?
Korotkoff sounds Phase II Swishing
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
oximetry
hypertension

19. How does the time of day (circadian rhythm) affect the body's temperature?

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20. Pulse lower than 60 beats per minute
Stertor
bradycardia
fever
120-139/80-89

21. Absence of breathing
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.
Apical
apnea

22. 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 Phase IV: Muffling
The pulse rate gradually diminishes from birth to adulthood
BMR

23. Rectal temperature are
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.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
hypertension
about 1 degree higher than oral temperatures

24. Newborn
30-80
low
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Kussmaul's respiration

25. Alternating rise and fall of the temperature.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Conduction
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
intermittent

26. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
low BP
shallow or slow breathing
constant
120-139/80-89

27. What are the 5 vital signs?
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
30-80
temperature - pulse - respiration - blood pressure - and pain level.
+3

28. How should respirations be counted?
Hyperventilation
pyrogens
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
crackles

29. Korotkoff sounds Ausculatatory gap:
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
arrhythmia
60 to 70 mL
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

30. Barely palpable
Blood pressure increases because there is more volume of blood in the vascular system.
Irregular
Feeble
oximetry

31. When should rectal temperatures be used?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
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
97.5 to 99.5
remittent

32. Abrupt decline in fever
+3
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
Korotkoff sounds Phase III: Knocking
Crisis

33. Hearing
140-159/90-99
+3
carotid
ausculatation

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

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35. How is shock caused?
hypoxemia
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.
140-159/90-99
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

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

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37. The temperature falls to normal and then rises again in a repeating pattern.
+2
Korotkoff sounds Phase III: Knocking
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.
Relapsing

38. How should baby's temperature be taken?
Respiration
+1
Axillary.
96.5 to 97.5

39. Bend of elbow
Eupnea
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Evaporation
Brachial

40. Stage 1 hypertension
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
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
140-159/90-99
Respiration

41. A normal - relaxed breathing pattern
Vascular resistance drops and the blood pressure decreases
Eupnea
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

42. Both strong and weak beats occur within 1 minute
Irregular
the blood pressure will rise in order to push the blood along.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
left Sims position

43. Weak and regular (even beats wit poor force)
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
+1
Crisis
Core Temperature

44. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
hypertension
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

45. Groin area
hypoxia
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.
bradypnea
Femoral

46. Slow and shallow breathing - leads to hypoxemia.
bradypnea
low
thready
Pulse

47. Fast - deep respirations with abrupt pauses

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48. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Posterior tibial
men - African Americans - under a lot of stress - obese
Stertor
12-20

49. Lobes in the lungs?
palpate
Nursing interventions to reduce fever
3 in the right lung and 2 lobes in the left
Posterior tibial

50. When the heart contracts How many mLs of blood is propelled into the aorta?
BMR
Stroke volume
Nursing interventions to reduce fever
60 to 70 mL

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Measuring Vital Signs

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