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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 increased body temperature increase the pulse?
constant
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Diastolic pressure
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

2. The maximum pressure exerted on the artery during left ventricular contraction.
Korotkoff sounds Phase II Swishing
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.
Systolic pressure
16-20

3. Normal body temperature ranges?
97.5 to 99.5
Diastolic pressure
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
popliteal

4. Those at risk for hypothermia include
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.
Dorsalis pedis
Axillary.
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.

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

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6. 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.
absent
12-20
Pulse pressure

7. Air movemtn causes heat to be transferred from the skin to the air molecules.
low BP
Convection
Rhonchi
Blood pressure increases because there is more volume of blood in the vascular system.

8. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
low BP
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
the lungs
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

9. A normal - relaxed breathing pattern
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Stertor
Eupnea
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

10. Rectal temperature are
stridor
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
about 1 degree higher than oral temperatures
bradycardia

11. Barely palpable
carotid
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Feeble
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

12. High oxygen
hyperoxia
140-159/90-99
apnea
stridor

13. right arm vs. left arm/ arm vs. leg BP?
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
the rate - the rhythm - and volume
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.
Increases as body tries to remove excess heat

14. Korotkoff sounds Phase I: Tapping
systolic pressure indicated by faint - clear sound that gradually grow louder.
140-159/90-99
hypoxemia
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

15. 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.
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
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
remittent
hyperoxia

16. Abrupt decline in 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.
Crisis
+3
97.5 to 99.5

17. Healthly adult
12-20
bradycardia
Biot's respirations
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.

18. Taking a rectal temperature
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Temporal
120/80
remittent

19. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Biot's respirations
Korotkoff sounds Phase IV: Muffling
120/70
Cardiac Output

20. Does the respiration rate increase or decrease during fever?
16-20
raises BP.
oximeter
Increases as body tries to remove excess heat

21. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
arrhythmia
Femoral
It will also fall
Korotkoff sounds Phase IV: Muffling

22. What affects does aging do to the respiratory rate?
Acute anxiety stimulate the nervous system - raising the pulse.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
apnea

23. Inside ankle
hypertension
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
+3
Posterior tibial

24. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
Axillary.
oximeter
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
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.

25. Excessive sweat production
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.
low BP
Diaphoresis
Korotkoff sounds Phase II Swishing

26. Both strong and weak beats occur within 1 minute
tachycardia
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
Irregular
palpate

27. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
crackles
shallow or slow breathing
Nursing interventions to reduce fever
Brachial

28. Elevated temperature
fever
Diaphoresis
Acute anxiety stimulate the nervous system - raising the pulse.
Nursing interventions to reduce fever

29. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
Rhonchi
constant
temperature - pulse - respiration - blood pressure - and pain level.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

30. Difference between the apical and radial pulse - this requires two people to count the radial and apicial pulses at the same time to determine whether there is a what?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Temporal
Vascular resistance drops and the blood pressure decreases

31. How does disease increase the body's temperature?
shallow or slow breathing
palpate
Dorsalis pedis
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

32. Sex BP?
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
Core Temperature
males have higher bp - until menopause then they are the same
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.

33. When should rectal temperatures be used?
raises BP.
Increases as body tries to remove excess heat
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
wheeze

34. When is apicial pulse used?
orthostatic hypertension
20-30
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.
Cardiac Output

35. Hearing
120/80
ausculatation
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Hypothermia

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
Nursing interventions to reduce fever
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
thready
remittent

37. Diurnal variation BP?
Increases as body tries to remove excess heat
blood pressure is lowest in the morning. and higher in the afternoone
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
140-159/90-99

38. The temperature of the deep tissues of the body
Core Temperature
72 bpm
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
from drug therapy - a neurologic problem or dehydration.

39. Pulse above 100 beats per minute
97.5 to 99.5
tachycardia
Hypothermia
Korotkoff sounds Phase V: Silence

40. Drop in blood pressure when arising to a standing position.
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
hypotension
orthostatic hypertension
Relapsing

41. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Diaphoresis
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Sinoatrial node (SA NODE)
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

42. 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.
Dorsalis pedis
temperature - pulse - respiration - blood pressure - and pain level.
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

43. Groin area
Tall - slender people mayy ave a slower pulse rate than short - stout persons
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Femoral
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

44. What happens when vasodilation occurs?
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
Vascular resistance drops and the blood pressure decreases
Kussmaul's respiration
the blood pressure will rise in order to push the blood along.

45. Prehypertension
hypoxia
low
120-139/80-89
Hypothermia

46. Murmur or swishing sounds that increase as the cuff is deflated
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Korotkoff sounds Phase II Swishing
men - African Americans - under a lot of stress - obese
Respiration

47. Stress & emotions. BP?
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
higher
Biot's
Pulse pressure

48. Korotkoff sounds Ausculatatory gap:
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 doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
orthostatic hypertension

49. Side of forehead
popliteal
low
Hyperthermia related to infection or excessive heat exposure
Temporal

50. Blood pressure for any adult should be no higher than
120/80
higher
120/70
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.