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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. When is apicial pulse used?
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.
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
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.
blood pressure is lowest in the morning. and higher in the afternoone

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

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3. 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
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Nursing interventions to reduce fever
Tachypnea
^160/^100

4. An example of nursing planning
97.5 to 99.5
^160/^100
Temperature will remain below 102 degrees with use of hypothermia blanket
Convection

5. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
from drug therapy - a neurologic problem or dehydration.
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.
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.
stridor

6. Subnormal body temperature the regulating center in the hypothalamus is greatly impaired when the temperature of the body falls below 94 degrees - at that point? sleepiness and coma are apt to develop.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
the blood pressure will rise in order to push the blood along.
Hypothermia
Crisis

7. Bend of elbow
+2
Stroke Volume
constant
Brachial

8. 2nd stage of fever is?
Nursing interventions to reduce fever
intermittent
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.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

9. Full and bounding (even beats wit strong force)
Core Temperature
systolic pressure indicated by faint - clear sound that gradually grow louder.
Hyperthermia related to infection or excessive heat exposure
+3

10. Sex BP?
low BP
intermittent
males have higher bp - until menopause then they are the same
Pons and Medulla of the brainstem

11. When should rectal temperatures NOT be used?
Posterior tibial
cardiac patients or patients who have had rectal surgery.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

12. No pulse palpable or heard on ausculation
Pons and Medulla of the brainstem
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.
12-20
absent

13. Side of forehead
Radial
oximetry
BMR
Temporal

14. How do drugs affect pulse?
crackles
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
12-20
120/80

15. Those at risk for hypothermia include
Brachial
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.
Kussmaul's respiration
Hyperventilation

16. Weak and regular (even beats wit poor force)
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
hyperoxia
Femoral
+1

17. Abrupt decline in fever
Crisis
stridor
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Korotkoff sounds Phase IV: Muffling

18. Hearing
ausculatation
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Tachypnea
constant

19. Lobes in the lungs?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
3 in the right lung and 2 lobes in the left
Diastolic pressure

20. How should baby's temperature be taken?
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.
Korotkoff sounds Phase II Swishing
Axillary.
Pulse pressure

21. Enviromental temperature BP?
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Crisis
lysis
Hyperthermia related to infection or excessive heat exposure

22. Stage 2 hypertension
the lungs
the rate - the rhythm - and volume
^160/^100
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

23. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Diastolic pressure
Pulse pressure
Pons and Medulla of the brainstem
Cheyenne-Stokes

24. Obtaining the correct size for a cuff for BP?
Dorsalis pedis
Pulse
12-20
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

25. What patients should not use a glass thermometer orally?
pyrexia
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
uncooperative patient - children - combative patients - dementia

26. How does physical exercise raise the body's temperature?
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.
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
Korotkoff sounds Phase III: Knocking

27. How does size affect pulse?
30-80
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
about 1 degree higher than oral temperatures
Tall - slender people mayy ave a slower pulse rate than short - stout persons

28. Average blood pressure should be
120/70
Stertor
popliteal
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

29. This affects the character of the pulse.
Stroke Volume
shallow or slow breathing
carotid
the blood pressure will rise in order to push the blood along.

30. Groin area
Femoral
3 in the right lung and 2 lobes in the left
96.5 to 97.5
Temporal

31. How should respirations be counted?
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Diastolic pressure
systolic pressure indicated by faint - clear sound that gradually grow louder.
absent

32. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
It increases to push the blood through more rigid pathways.
Crisis
Feeble

33. 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 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
Cardiac Output
Irregular
Korotkoff sounds Phase V: Silence

34. 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.
Korotkoff sounds
uncooperative patient - children - combative patients - dementia
30-80
remittent

35. State of insufficient oxygen
hypoxia
systolic pressure indicated by faint - clear sound that gradually grow louder.
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.
Diaphoresis

36. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Sinoatrial node (SA NODE)
Radial
140-159/90-99
hypoxia

37. Drop in blood pressure when arising to a standing position.
stridor
orthostatic hypertension
+2
left Sims position

38. Axillary temperature are
popliteal
Rhonchi
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.
about 1 degree lower than oral temperatures

39. When the heart contracts How many mLs of blood is propelled into the aorta?
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.
60 to 70 mL
Feeble
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

40. What happens to the blood if overhydration occurs?
Feeble
absent
Blood pressure increases because there is more volume of blood in the vascular system.
uncooperative patient - children - combative patients - dementia

41. Absence of breathing
Irregular
the lungs
The emotions increase hormone secretion - and the body activities required for this increase heat production.
apnea

42. The rate at which heat is produced when the body is at rest.
hypoxia
BMR
Stertor
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

43. Adolescent
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.
16-20
in the alveoli - tiny thin-walled sacs
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

44. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
men - African Americans - under a lot of stress - obese
the blood pressure will rise in order to push the blood along.
16-20
uncooperative patient - children - combative patients - dementia

45. How do you measure the apical pulse?
16-20
Pons and Medulla of the brainstem
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
hypoxemia

46. 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?
about 1 degree lower than oral temperatures
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
pyrexia
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

47. Healthly adult
The emotions increase hormone secretion - and the body activities required for this increase heat production.
in the alveoli - tiny thin-walled sacs
12-20
dyspnea

48. When warm skin touches a cool object - heat is lost to the object.
the rate - the rhythm - and volume
It will also fall
Conduction
Respiration

49. Average pulse rate for an adult
+1
It will also fall
thready
72 bpm

50. Elevated temperature
Biot's respirations
Korotkoff sounds Phase II Swishing
fever
20-30