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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
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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. Enviromental temperature BP?
pyrexia
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
dyspnea
intermittent

2. The temperature of the deep tissues of the body
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
Cheyenne-Stokes
It will also fall
Core Temperature

3. What patients should not use a glass thermometer orally?
60 to 70 mL
constant
hypoxia
uncooperative patient - children - combative patients - dementia

4. Alternating rise and fall of the temperature.
Pons and Medulla of the brainstem
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.
intermittent
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

5. Korotkoff sounds Phase I: Tapping
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
systolic pressure indicated by faint - clear sound that gradually grow louder.
Systolic pressure

6. Top of left foot
Stroke Volume
Irregular
Dorsalis pedis
Axillary.

7. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Evaporation
Stroke Volume
about 1 degree lower than oral temperatures
thready

8. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
pyrexia
Biot's respirations
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

9. People most at risk for hypertension
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
men - African Americans - under a lot of stress - obese
Tall - slender people mayy ave a slower pulse rate than short - stout persons
blood pressure is lowest in the morning. and higher in the afternoone

10. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
Acute anxiety stimulate the nervous system - raising the pulse.
low BP
Biot's
about 1 degree higher than oral temperatures

11. When should rectal temperatures be used?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
shallow or slow breathing
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
20-30

12. What should you do if you cannot determine BP by ausculation?
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
apnea
12-20
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.

13. Sex BP?
Korotkoff sounds
120/70
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
males have higher bp - until menopause then they are the same

14. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Evaporation
ausculatation
shallow or slow breathing
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

15. Fever above 100.2 F
Acute anxiety stimulate the nervous system - raising the pulse.
pyrexia
Biot's respirations
Hyperventilation

16. Taking a rectal temperature
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
blood pressure is lowest in the morning. and higher in the afternoone
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
arrhythmia

17. How does emotional stress raise the body's temperature?
uncooperative patient - children - combative patients - dementia
The emotions increase hormone secretion - and the body activities required for this increase heat production.
12-20
cardiac patients or patients who have had rectal surgery.

18. How should respirations be counted?
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
carotid
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
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.

19. What characteristics should be noted when checking the pulse?
stridor
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
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
the rate - the rhythm - and volume

20. Slow and shallow breathing - leads to hypoxemia.
lysis
Convection
bradypnea
^160/^100

21. The pulse rate multiplied by the stroke volume. This is the amount of blood pumped by the left ventricle in 1 minute. Averaging at about 5mL per minute.
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.
Korotkoff sounds Phase II Swishing
Cardiac Output
^160/^100

22. Disappearance of sound. (marks diastolic pressure in adults)
shallow or slow breathing
Tachypnea
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Korotkoff sounds Phase V: Silence

23. The rate at which heat is produced when the body is at rest.
Feeble
about 1 degree higher than oral temperatures
tachycardia
BMR

24. The volume of blood pushed into the aorta per heartbeat.
120-139/80-89
3 in the right lung and 2 lobes in the left
Stroke volume
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

25. Symptoms of hypoxia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
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
Relapsing
Stertor

26. Are infants blood pressure low or high?
wheeze
popliteal
low
BMR

27. Stage 2 hypertension
^160/^100
+1
about 1 degree lower than oral temperatures
the lungs

28. 3 yr old
hypertension
20-30
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 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

29. How do drugs affect pulse?
hypertension
men - African Americans - under a lot of stress - obese
Stroke Volume
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

30. Side of forehead
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.
Temporal
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

31. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Stertor
hypoxemia
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

32. Bend of knee
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
palpate
low BP
popliteal

33. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
Systolic pressure
crackles
Crisis
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.

34. Shallow for two or three breaths with a period of variable apnea. occur in patients with increased intracranial pressure.

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

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36. Barely palpable
Pulse
absent
Feeble
Pons and Medulla of the brainstem

37. When should rectal temperatures NOT be used?
left Sims position
Korotkoff sounds Phase IV: Muffling
cardiac patients or patients who have had rectal surgery.
Pulse

38. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Sinoatrial node (SA NODE)
temperature - pulse - respiration - blood pressure - and pain level.
It will also fall
about 1 degree higher than oral temperatures

39. Side of neck
Blood pressure increases because there is more volume of blood in the vascular system.
hypotension
carotid
Tall - slender people mayy ave a slower pulse rate than short - stout persons

40. State of insufficient oxygen
hypoxia
low BP
120/80
temperature - pulse - respiration - blood pressure - and pain level.

41. Blood pressure for any adult should be no higher than
120/80
hypoxia
left Sims position
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

42. Substances tat cause fever
Relapsing
pyrogens
about 1 degree higher than oral temperatures
bradycardia

43. Low oxygen
The emotions increase hormone secretion - and the body activities required for this increase heat production.
hypoxia
+1
^160/^100

44. Stress & emotions. BP?
Biot's respirations
Core Temperature
higher
raises BP.

45. 2nd stage of fever is?
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
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
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.

46. How does increased body temperature increase the pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
The pulse rate gradually diminishes from birth to adulthood
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Korotkoff sounds Phase IV: Muffling

47. Elevated temperature
fever
Convection
20-30
Systolic pressure

48. An example of a nursing diagnoses
Stroke Volume
Kussmaul's respiration
Hyperthermia related to infection or excessive heat exposure
Radial

49. Does the respiration rate increase or decrease during fever?
Pedal pulse
lysis
Increases as body tries to remove excess heat
hypotension

50. 3rd stage of fever?
orthostatic hypertension
Korotkoff sounds Phase IV: Muffling
Eupnea
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

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Measuring Vital Signs

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