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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. What are the 5 vital signs?
pyrogens
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.
16-20
temperature - pulse - respiration - blood pressure - and pain level.

2. Side of forehead
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
absent
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

3. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Irregular
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Stertor
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.

4. Bend of elbow
Hyperthermia related to infection or excessive heat exposure
97.5 to 99.5
Vascular resistance drops and the blood pressure decreases
Brachial

5. Groin area
Vascular resistance drops and the blood pressure decreases
Femoral
Korotkoff sounds
Irregular

6. The difference between the systolic pressure and the diastolic pressure
Eupnea
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.
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.
Pulse pressure

7. right arm vs. left arm/ arm vs. leg BP?
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.
bradypnea
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Korotkoff sounds Phase III: Knocking

8. What should you do if you cannot determine BP by ausculation?
+1
Korotkoff sounds Phase V: Silence
popliteal
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.

9. Does the respiration rate increase or decrease during fever?
Hyperthermia related to infection or excessive heat exposure
Cardiac Output
97.5 to 99.5
Increases as body tries to remove excess heat

10. Slow and shallow breathing - leads to hypoxemia.
96.5 to 97.5
bradypnea
shallow or slow breathing
raises BP.

11. Average blood pressure should be
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
^160/^100
120/70
Stroke Volume

12. Whats the best position to take a rectal temperature?
left Sims position
low
Kussmaul's respiration
Stroke Volume

13. Abrupt decline in fever
Sinoatrial node (SA NODE)
Crisis
Pulse pressure
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

14. How does disease increase the body's temperature?
about 1 degree lower than oral temperatures
pyrexia
Femoral
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

15. Axillary temperature are
Hyperventilation
Stertor
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.
about 1 degree lower than oral temperatures

16. 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 III: Knocking
Cheyenne-Stokes
low BP

17. BP at or lower 90/60.
Respiration
Eupnea
hypotension
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.

18. Weak and regular (even beats wit poor force)
hypoxia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
+1
stridor

19. An example of a nursing diagnoses
Stroke Volume
Hyperthermia related to infection or excessive heat exposure
Radial
Pulse

20. When warm skin touches a cool object - heat is lost to the object.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Eupnea
Conduction
It increases to push the blood through more rigid pathways.

21. When the heart contracts How many mLs of blood is propelled into the aorta?
^160/^100
+1
temperature - pulse - respiration - blood pressure - and pain level.
60 to 70 mL

22. Measurement of oxygen
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
oximetry
Hypothermia
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.

23. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
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.
Biot's
tachycardia

24. A normal - relaxed breathing pattern
Nursing interventions to reduce fever
Respiration
Pulse
Eupnea

25. Pulse lower than 60 beats per minute
140-159/90-99
men - African Americans - under a lot of stress - obese
bradycardia
about 1 degree lower than oral temperatures

26. Fast - deep respirations with abrupt pauses

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27. Absence of breathing
Hyperventilation
the blood pressure will rise in order to push the blood along.
hypoxia
apnea

28. How do emotions increase the pulse rate?
Acute anxiety stimulate the nervous system - raising the pulse.
Vascular resistance drops and the blood pressure decreases
Hyperthermia related to infection or excessive heat exposure
Pedal pulse

29. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Rhonchi
blood pressure is lowest in the morning. and higher in the afternoone
left Sims position
Cheyenne-Stokes

30. How does menstrual cycle and pregnancy raise the body's temperature?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Korotkoff sounds Phase V: Silence
Temperature will remain below 102 degrees with use of hypothermia blanket
Pulse pressure

31. A pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled - causing te blood level of carbon dioxide to fall. this condition is seen after sever exertion - during high levels of anxiety o
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Hyperventilation
Stroke volume

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

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33. The volume of blood pushed into the aorta per heartbeat.
systolic pressure indicated by faint - clear sound that gradually grow louder.
fever
left Sims position
Stroke volume

34. How do you measure the apical pulse?
intermittent
3 in the right lung and 2 lobes in the left
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 rate - the rhythm - and volume

35. Inside ankle
low BP
the rate - the rhythm - and volume
Relapsing
Posterior tibial

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

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37. When should rectal temperatures NOT be used?
3 in the right lung and 2 lobes in the left
Radial
Core Temperature
cardiac patients or patients who have had rectal surgery.

38. When should rectal temperatures be used?
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
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
Nursing interventions to reduce fever
30-80

39. Drop in blood pressure when arising to a standing position.
arrhythmia
Stertor
orthostatic hypertension
Diaphoresis

40. Murmur or swishing sounds that increase as the cuff is deflated
Relapsing
Nursing interventions to reduce fever
Korotkoff sounds Phase II Swishing
Respiration

41. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
orthostatic hypertension
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
oximeter
from drug therapy - a neurologic problem or dehydration.

42. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
Diastolic pressure
Pulse
Radial
It increases to push the blood through more rigid pathways.

43. Are infants blood pressure low or high?
Pons and Medulla of the brainstem
apnea
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
low

44. Normal body temperature ranges?
30-80
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
97.5 to 99.5
120/70

45. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Cheyenne-Stokes
Radial
Nursing interventions to reduce fever
Evaporation

46. Top of left foot
arrhythmia
Kussmaul's respiration
Femoral
Dorsalis pedis

47. Stage 2 hypertension
systolic pressure indicated by faint - clear sound that gradually grow louder.
Vascular resistance drops and the blood pressure decreases
Kussmaul's respiration
^160/^100

48. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
120/80
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
low BP
Korotkoff sounds Phase V: Silence

49. Louder knocking sound that occurs wit each heartbeat
blood pressure is lowest in the morning. and higher in the afternoone
Korotkoff sounds Phase III: Knocking
Pulse pressure
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

50. Adolescent
Convection
16-20
hypoxemia
dyspnea