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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. Disappearance of sound. (marks diastolic pressure in adults)
Rhonchi
Blood pressure increases because there is more volume of blood in the vascular system.
Korotkoff sounds Phase V: Silence
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

2. Side of neck
carotid
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
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
low

3. High BP
Korotkoff sounds Phase IV: Muffling
Acute anxiety stimulate the nervous system - raising the pulse.
Core Temperature
hypertension

4. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
carotid
120/70
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
dyspnea

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

6. How does size affect pulse?
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.
hypotension
Tall - slender people mayy ave a slower pulse rate than short - stout persons
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.

7. Fast - deep respirations with abrupt pauses

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8. 1st stage of fever is?
Temporal
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Respiration
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

9. Inside ankle
3 in the right lung and 2 lobes in the left
Posterior tibial
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.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

10. The volume of blood pushed into the aorta per heartbeat.
Temporal
Stroke volume
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
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.

11. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
bradypnea
Pulse
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
120/70

12. Obtaining the correct size for a cuff for BP?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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.
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
16-20

13. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
low BP
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 III: Knocking

14. How does age affect pulse?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Sinoatrial node (SA NODE)
The pulse rate gradually diminishes from birth to adulthood
apnea

15. Murmur or swishing sounds that increase as the cuff is deflated
^160/^100
Evaporation
Korotkoff sounds Phase II Swishing
Pulse pressure

16. Average blood pressure should be
raises BP.
120/70
Biot's respirations
Relapsing

17. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Temporal
Korotkoff sounds Phase II Swishing
Biot's respirations
Korotkoff sounds Phase IV: Muffling

18. Slow and shallow breathing - leads to hypoxemia.
Core Temperature
bradypnea
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
60 to 70 mL

19. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
bradypnea
Korotkoff sounds
BMR
bradycardia

20. Healthly adult
Rhonchi
Korotkoff sounds Phase III: Knocking
apnea
12-20

21. Full and bounding (even beats wit strong force)
absent
+3
+2
about 1 degree lower than oral temperatures

22. Abnormal - nonmusical sound heard on ausculation of the lungs during inspiration; also called rales. Sound like hair rubbed between the fingers next to the ears.
Cardiac Output
16-20
higher
crackles

23. 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.
bradypnea
BMR
96.5 to 97.5
hypoxemia

24. Lobes in the lungs?
16-20
3 in the right lung and 2 lobes in the left
shallow or slow breathing
low BP

25. Risk for prolonged hypertension
Feeble
temperature - pulse - respiration - blood pressure - and pain level.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Evaporation

26. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
hypotension
Eupnea
bradypnea
Diastolic pressure

27. An example of nursing planning
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
raises BP.
Temperature will remain below 102 degrees with use of hypothermia blanket
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.

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

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29. Gradual return to a normal temperature
Acute anxiety stimulate the nervous system - raising the pulse.
lysis
remittent
males have higher bp - until menopause then they are the same

30. Gas exchange in the blood occurs where?
Temporal
Respiration
+2
in the alveoli - tiny thin-walled sacs

31. If the cardiac output falls what will happen to the BP?
It will also fall
Pons and Medulla of the brainstem
Pulse
+3

32. How is pulse best found?
Respiration
apnea
The pulse rate gradually diminishes from birth to adulthood
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. No pulse palpable or heard on ausculation
absent
120-139/80-89
Sinoatrial node (SA NODE)
Pulse pressure

34. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
+1
bradypnea
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
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. Side of forehead
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
Temporal
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
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.

36. Low oxygen
hypoxia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
hyperoxia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

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

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38. When should rectal temperatures be used?
intermittent
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
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
dyspnea

39. Korotkoff sounds Phase I: Tapping
systolic pressure indicated by faint - clear sound that gradually grow louder.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
males have higher bp - until menopause then they are the same
Korotkoff sounds

40. What happens when vasodilation occurs?
Vascular resistance drops and the blood pressure decreases
systolic pressure indicated by faint - clear sound that gradually grow louder.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
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.

41. 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
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
ausculatation
Hyperventilation
Korotkoff sounds

42. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
hypertension
The pulse rate gradually diminishes from birth to adulthood
hypoxemia
It increases to push the blood through more rigid pathways.

43. Fever above 100.2 F
Tall - slender people mayy ave a slower pulse rate than short - stout persons
systolic pressure indicated by faint - clear sound that gradually grow louder.
pyrexia
97.5 to 99.5

44. What pulse is checked to determine whether there is any blockage of circulation in the artery up to that point - especially in patients who have had cardiac catherization using the femoral artery for the insertion of the catheter or those who had sur
hyperoxia
constant
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Pedal pulse

45. Bend of knee
Feeble
popliteal
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Conduction

46. When should rectal temperatures NOT be used?
males have higher bp - until menopause then they are the same
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
cardiac patients or patients who have had rectal surgery.
Axillary.

47. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
Conduction
20-30
Femoral

48. Stage 2 hypertension
The emotions increase hormone secretion - and the body activities required for this increase heat production.
remittent
^160/^100
Relapsing

49. What are the 5 vital signs?
temperature - pulse - respiration - blood pressure - and pain level.
96.5 to 97.5
Vascular resistance drops and the blood pressure decreases
remittent

50. 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
uncooperative patient - children - combative patients - dementia
hypotension

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Measuring Vital Signs

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