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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. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Pulse
^160/^100
16-20
hypotension

2. 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
Vascular resistance drops and the blood pressure decreases
Respiration
hypotension
Nursing interventions to reduce fever

3. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
cardiac patients or patients who have had rectal surgery.
^160/^100
Evaporation
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.

4. Fever above 100.2 F
pyrexia
96.5 to 97.5
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

5. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
Hyperventilation
stridor
absent
Korotkoff sounds Phase III: Knocking

6. Lobes in the lungs?
hypotension
3 in the right lung and 2 lobes in the left
fever
60 to 70 mL

7. 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.
Increases as body tries to remove excess heat
Femoral
tachycardia
hypoxemia

8. Substances tat cause fever
constant
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
pyrogens
Cardiac Output

9. 3 yr old
20-30
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Korotkoff sounds Phase II Swishing

10. Signs and symptoms of shock
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Axillary.
Hyperventilation
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

11. When the heart contracts How many mLs of blood is propelled into the aorta?
uncooperative patient - children - combative patients - dementia
wheeze
Acute anxiety stimulate the nervous system - raising the pulse.
60 to 70 mL

12. How should baby's temperature be taken?
20-30
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.
Axillary.
Sinoatrial node (SA NODE)

13. 2nd stage of fever is?
tachycardia
97.5 to 99.5
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.
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.

14. Pulse lower than 60 beats per minute
bradycardia
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
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.
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.

15. By measuring the blood pressure you obtain vital info about what?
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 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
Blood pressure increases because there is more volume of blood in the vascular system.

16. Elevated temperature
raises BP.
palpate
fever
Dorsalis pedis

17. Low oxygen
30-80
Stertor
hypoxia
Convection

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

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19. 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.
constant
hypoxia
140-159/90-99
remittent

20. Full and bounding (even beats wit strong force)
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.
+3
apnea
Axillary.

21. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
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.
about 1 degree higher than oral temperatures
Nursing interventions to reduce fever
wheeze

22. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
thready
oximeter
apnea
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

23. What affects does aging do to the heart rate?

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24. Hearing
Core Temperature
+1
raises BP.
ausculatation

25. The maximum pressure exerted on the artery during left ventricular contraction.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Systolic pressure
Radial
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.

26. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
fever
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Respiration

27. High oxygen
Evaporation
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
hypoxia
hyperoxia

28. Excessive sweat production
apnea
lysis
systolic pressure indicated by faint - clear sound that gradually grow louder.
Diaphoresis

29. How does emotional stress raise the body's temperature?
Korotkoff sounds Phase IV: Muffling
the blood pressure will rise in order to push the blood along.
Korotkoff sounds
The emotions increase hormone secretion - and the body activities required for this increase heat production.

30. Top of left foot
Diaphoresis
Korotkoff sounds Phase IV: Muffling
Dorsalis pedis
Biot's

31. 1st stage of fever is?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
+3
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
wheeze

32. How does size affect pulse?
120/80
Vascular resistance drops and the blood pressure decreases
Tall - slender people mayy ave a slower pulse rate than short - stout persons
bradycardia

33. Fast - deep respirations with abrupt pauses

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34. Taking axillary 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.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
from drug therapy - a neurologic problem or dehydration.
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.

35. Stress & emotions. BP?
higher
Dorsalis pedis
systolic pressure indicated by faint - clear sound that gradually grow louder.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

36. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Pons and Medulla of the brainstem
dyspnea
30-80
BMR

37. An example of a nursing diagnoses
Stroke volume
Korotkoff sounds Phase III: Knocking
Hyperthermia related to infection or excessive heat exposure
Biot's respirations

38. Strong and regular ( even beats wit moderate force)
Tall - slender people mayy ave a slower pulse rate than short - stout persons
+2
16-20
lysis

39. Adolescent
Temporal
hypoxemia
16-20
3 in the right lung and 2 lobes in the left

40. Groin area
pyrexia
Hypothermia
shallow or slow breathing
Femoral

41. How should respirations be counted?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
hyperoxia
Femoral

42. Elderly respiration
Irregular
men - African Americans - under a lot of stress - obese
the rate - the rhythm - and volume
16-20

43. Rectal temperature are
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
bradycardia
Axillary.
about 1 degree higher than oral temperatures

44. Whats the best position to take a rectal temperature?
left Sims position
palpate
Radial
Relapsing

45. Average blood pressure should be
intermittent
120/70
Korotkoff sounds Phase III: Knocking
Temporal

46. Prehypertension
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.
Nursing interventions to reduce fever
systolic pressure indicated by faint - clear sound that gradually grow louder.
120-139/80-89

47. BP at or lower 90/60.
wheeze
120-139/80-89
hypotension
palpate

48. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
about 1 degree higher than oral temperatures
constant
about 1 degree lower than oral temperatures
Vascular resistance drops and the blood pressure decreases

49. Head injury BP?
raises BP.
stridor
Nursing interventions to reduce fever
Cardiac Output

50. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
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.
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.
shallow or slow breathing
3 in the right lung and 2 lobes in the left

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Measuring Vital Signs

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