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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 do emotions increase the pulse rate?
Convection
^160/^100
Increases as body tries to remove excess heat
Acute anxiety stimulate the nervous system - raising the pulse.

2. Absence of breathing
Korotkoff sounds Phase II Swishing
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.
+1
apnea

3. Rectal temperature are
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.
about 1 degree higher than oral temperatures
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
absent

4. The maximum pressure exerted on the artery during left ventricular contraction.
Apical
bradypnea
Systolic pressure
intermittent

5. Axillary temperature are
about 1 degree lower than oral temperatures
Axillary.
men - African Americans - under a lot of stress - obese
oximeter

6. Whats the best position to take a rectal temperature?
blood pressure is lowest in the morning. and higher in the afternoone
left Sims position
16-20
shallow or slow breathing

7. Weak and regular (even beats wit poor force)
Korotkoff sounds Phase II Swishing
Pulse
+1
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.

8. Obtaining the correct size for a cuff for BP?
Brachial
^160/^100
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
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

9. Bend of elbow
Vascular resistance drops and the blood pressure decreases
Brachial
apnea
^160/^100

10. Normal body temperature ranges?
Temperature will remain below 102 degrees with use of hypothermia blanket
97.5 to 99.5
hypoxemia
Korotkoff sounds

11. 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
Nursing interventions to reduce fever
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.
Eupnea
+1

12. 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.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

13. Those at risk for hypothermia include
pyrogens
72 bpm
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.
low BP

14. Elderly respiration
Nursing interventions to reduce fever
Kussmaul's respiration
Pulse
16-20

15. Weak and may be irregular
thready
bradycardia
Posterior tibial
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

16. An example of a nursing diagnoses
about 1 degree higher than oral temperatures
hypoxia
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.
Hyperthermia related to infection or excessive heat exposure

17. What are the 5 vital signs?
bradypnea
temperature - pulse - respiration - blood pressure - and pain level.
left Sims position
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.

18. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
pyrexia
120-139/80-89
Brachial

19. The temperature of the deep tissues of the body
^160/^100
Core Temperature
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
males have higher bp - until menopause then they are the same

20. How does emotional stress raise the body's temperature?
orthostatic hypertension
The emotions increase hormone secretion - and the body activities required for this increase heat production.
carotid
crackles

21. How does increased body temperature increase the pulse?
12-20
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
about 1 degree lower than oral temperatures
The pulse rate gradually diminishes from birth to adulthood

22. Gradual return to a normal temperature
lysis
Biot's
+3
cardiac patients or patients who have had rectal surgery.

23. When should rectal temperatures be used?
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
30-80
Convection
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

24. Louder knocking sound that occurs wit each heartbeat
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Posterior tibial
Korotkoff sounds Phase III: Knocking
stridor

25. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
pyrogens
about 1 degree lower than oral temperatures
stridor
Korotkoff sounds Phase IV: Muffling

26. 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.
remittent
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
the blood pressure will rise in order to push the blood along.
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.

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

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28. Breathing is an involuntary automatic function controlled by the respiratory center located where?
16-20
Pons and Medulla of the brainstem
crackles
Relapsing

29. Lobes in the lungs?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
+2
Korotkoff sounds Phase II Swishing
3 in the right lung and 2 lobes in the left

30. Top of left foot
Dorsalis pedis
Axillary.
Cheyenne-Stokes
30-80

31. What happens when vasodilation occurs?
left Sims position
remittent
Vascular resistance drops and the blood pressure decreases
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

32. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
oximeter
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
pyrexia
hypertension

33. Does the respiration rate increase or decrease during fever?
Vascular resistance drops and the blood pressure decreases
Increases as body tries to remove excess heat
Diastolic pressure
Hyperventilation

34. How should baby's temperature be taken?
Rhonchi
16-20
Axillary.
Brachial

35. Are infants blood pressure low or high?
Cardiac Output
Biot's
low
+2

36. Blood pressure for any adult should be no higher than
Kussmaul's respiration
120/80
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.
It will also fall

37. The volume of blood pushed into the aorta per heartbeat.
Stroke volume
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.
crackles
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

38. A normal - relaxed breathing pattern
hypoxia
Hyperventilation
Eupnea
Diaphoresis

39. Abrupt decline in fever
Femoral
Apical
Crisis
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

40. Full and bounding (even beats wit strong force)
140-159/90-99
+3
16-20
Core Temperature

41. Slow and shallow breathing - leads to hypoxemia.
bradypnea
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
96.5 to 97.5
Hyperventilation

42. 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
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
140-159/90-99
12-20

43. Enviromental temperature BP?
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.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
72 bpm

44. Healthly adult
pyrogens
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.
Cheyenne-Stokes
12-20

45. Taking axillary temperature
Korotkoff sounds
Core Temperature
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.
Hypothermia

46. How cardiac contractions are normally initiated by the electrical impules emerging from what?
constant
Sinoatrial node (SA NODE)
It increases to push the blood through more rigid pathways.
120/80

47. The rate at which heat is produced when the body is at rest.
carotid
males have higher bp - until menopause then they are the same
It increases to push the blood through more rigid pathways.
BMR

48. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Stroke volume
Increases as body tries to remove excess heat
Rhonchi
Posterior tibial

49. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Cheyenne-Stokes
oximetry
Hypothermia
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.

50. Air movemtn causes heat to be transferred from the skin to the air molecules.
Stroke Volume
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
palpate
Convection