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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

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. Taking axillary temperature
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Eupnea
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.
Cardiac Output

2. Signs and symptoms of shock
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Dorsalis pedis
Sinoatrial node (SA NODE)
intermittent

3. Stress & emotions. BP?
absent
Stroke Volume
+3
higher

4. Air movemtn causes heat to be transferred from the skin to the air molecules.
Femoral
Convection
in the alveoli - tiny thin-walled sacs
Irregular

5. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
hypertension
^160/^100
Vascular resistance drops and the blood pressure decreases
the blood pressure will rise in order to push the blood along.

6. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Pons and Medulla of the brainstem
Dorsalis pedis
Korotkoff sounds Phase V: Silence
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.

7. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Temperature will remain below 102 degrees with use of hypothermia blanket
left Sims position
Korotkoff sounds
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

8. What characteristics should be noted when checking the pulse?
Kussmaul's respiration
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
the rate - the rhythm - and volume

9. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Rhonchi
bradycardia
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
bradypnea

10. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
Brachial
Pons and Medulla of the brainstem
oximeter
It will also fall

11. How does emotional stress raise the body's temperature?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
constant
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.

12. An example of a nursing diagnoses
Femoral
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Hyperthermia related to infection or excessive heat exposure

13. What should you do if you cannot determine BP by ausculation?
Stertor
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
hyperoxia
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.

14. High oxygen
Posterior tibial
hyperoxia
Sinoatrial node (SA NODE)
Hypothermia

15. Weak and may be irregular
dyspnea
thready
Brachial
raises BP.

16. Lobes in the lungs?
3 in the right lung and 2 lobes in the left
Core Temperature
Radial
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

17. How is pulse best found?
20-30
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
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.
tachycardia

18. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Tachypnea
low
left Sims position
wheeze

19. Obtaining the correct size for a cuff for BP?
Sinoatrial node (SA NODE)
Tall - slender people mayy ave a slower pulse rate than short - stout persons
fever
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

20. State of insufficient oxygen
hypoxia
hyperoxia
Cardiac Output
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

21. Heart
Apical
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 pulse rate increases at the rate of 7-10 beats for each degree of temperature
Stertor

22. Barely palpable
from drug therapy - a neurologic problem or dehydration.
Feeble
Systolic pressure
Diaphoresis

23. Fever above 100.2 F
30-80
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Axillary.
pyrexia

24. right arm vs. left arm/ arm vs. leg BP?
Korotkoff sounds Phase II Swishing
hypoxia
stridor
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

25. Korotkoff sounds Ausculatatory gap:
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Korotkoff sounds
hypoxia
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

26. High BP
thready
hypertension
temperature - pulse - respiration - blood pressure - and pain level.
Cardiac Output

27. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Cheyenne-Stokes
Pulse
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

28. How should baby's temperature be taken?
Axillary.
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.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

29. Head injury BP?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Pulse pressure
raises BP.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

30. Stage 1 hypertension
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
16-20
140-159/90-99
Sinoatrial node (SA NODE)

31. The maximum pressure exerted on the artery during left ventricular contraction.
Systolic pressure
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
16-20
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

32. How is shock caused?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
palpate
in the alveoli - tiny thin-walled sacs

33. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Femoral
Korotkoff sounds Phase IV: Muffling
Posterior tibial
males have higher bp - until menopause then they are the same

34. Risk for prolonged hypertension
Diaphoresis
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
It increases to push the blood through more rigid pathways.
Biot's

35. How does size affect pulse?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
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.
Nursing interventions to reduce fever
+2

36. 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
popliteal
Nursing interventions to reduce fever
thready
+2

37. BP at or lower 90/60.
the lungs
hypotension
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
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.

38. The difference between the systolic pressure and the diastolic pressure
It increases to push the blood through more rigid pathways.
the rate - the rhythm - and volume
It will also fall
Pulse pressure

39. 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
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
20-30
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

40. 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.
The pulse rate gradually diminishes from birth to adulthood
arrhythmia
oximetry

41. Elderly respiration
120/80
16-20
orthostatic hypertension
72 bpm

42. Pulse lower than 60 beats per minute
Dorsalis pedis
bradycardia
97.5 to 99.5
oximeter

43. The rate at which heat is produced when the body is at rest.
palpate
BMR
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
shallow or slow breathing

44. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
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
Acute anxiety stimulate the nervous system - raising the pulse.
shallow or slow breathing

45. Gas exchange in the blood occurs where?
arrhythmia
in the alveoli - tiny thin-walled sacs
+1
Korotkoff sounds Phase III: Knocking

46. If the cardiac output falls what will happen to the BP?
uncooperative patient - children - combative patients - dementia
higher
It will also fall
Relapsing

47. 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
97.5 to 99.5
Rhonchi
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.
Pedal pulse

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

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49. Full and bounding (even beats wit strong force)
+3
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Conduction
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.

50. This affects the character of the pulse.
Systolic pressure
Stroke Volume
+1
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