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Test your basic knowledge |
Measuring Vital Signs
Start Test
Study First
Subjects
:
health-sciences
,
emergency-medicine
Instructions:
Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can
study here
.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.
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. An example of nursing planning
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Temperature will remain below 102 degrees with use of hypothermia blanket
Biot's
Hypothermia
2. High oxygen
orthostatic hypertension
dyspnea
hyperoxia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
3. Pulse above 100 beats per minute
Brachial
tachycardia
hyperoxia
The emotions increase hormone secretion - and the body activities required for this increase heat production.
4. How do you measure the apical pulse?
cardiac patients or patients who have had rectal surgery.
Korotkoff sounds Phase III: Knocking
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 pulse rate increases at the rate of 7-10 beats for each degree of temperature
5. Sex BP?
Diastolic pressure
12-20
Sinoatrial node (SA NODE)
males have higher bp - until menopause then they are the same
6. Excessive sweat production
hypoxia
Diaphoresis
low BP
Tachypnea
7. 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
Nursing interventions to reduce fever
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Respiration
Stroke volume
8. High BP
hypertension
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
It will also fall
Convection
9. Taking a rectal temperature
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full 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.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
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
10. Head injury BP?
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Nursing interventions to reduce fever
raises BP.
low BP
11. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
low BP
popliteal
Stroke volume
12. No pulse palpable or heard on ausculation
absent
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
+1
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
13. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
Hyperventilation
30-80
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.
cardiac patients or patients who have had rectal surgery.
14. Obtaining the correct size for a cuff for BP?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Irregular
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Stertor
15. When the heart contracts How many mLs of blood is propelled into the aorta?
Cheyenne-Stokes
low BP
60 to 70 mL
Stroke volume
16. How does age affect pulse?
^160/^100
bradypnea
Crisis
The pulse rate gradually diminishes from birth to adulthood
17. Healthly adult
Sinoatrial node (SA NODE)
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
12-20
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
18. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
It will also fall
Respiration
oximetry
19. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
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
pyrogens
Cheyenne-Stokes
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
20. Louder knocking sound that occurs wit each heartbeat
BMR
Korotkoff sounds Phase III: Knocking
blood pressure is lowest in the morning. and higher in the afternoone
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
21. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
The emotions increase hormone secretion - and the body activities required for this increase heat production.
60 to 70 mL
Korotkoff sounds Phase IV: Muffling
Brachial
22. What affects does aging do to the heart rate?
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23. How does menstrual cycle and pregnancy raise the body's temperature?
Increases as body tries to remove excess heat
72 bpm
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
24. Adolescent
^160/^100
remittent
stridor
16-20
25. Signs and symptoms of shock
Pons and Medulla of the brainstem
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
temperature - pulse - respiration - blood pressure - and pain level.
Korotkoff sounds Phase II Swishing
26. Barely palpable
Biot's
^160/^100
Feeble
the rate - the rhythm - and volume
27. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
the lungs
Stertor
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
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
28. Hearing
higher
ausculatation
Femoral
+1
29. Rectal temperature are
Korotkoff sounds Phase II Swishing
higher
about 1 degree higher than oral temperatures
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.
30. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Respiration
systolic pressure indicated by faint - clear sound that gradually grow louder.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
wheeze
31. Risk for prolonged hypertension
Core Temperature
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
+2
left Sims position
32. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
absent
oximeter
Pulse
3 in the right lung and 2 lobes in the left
33. Gas exchange in the blood occurs where?
pyrogens
remittent
120-139/80-89
in the alveoli - tiny thin-walled sacs
34. Top of left foot
blood pressure is lowest in the morning. and higher in the afternoone
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Dorsalis pedis
the blood pressure will rise in order to push the blood along.
35. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
96.5 to 97.5
It increases to push the blood through more rigid pathways.
palpate
Pulse
36. What affects does aging do to the respiratory rate?
popliteal
Radial
shallow or slow breathing
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
37. How does the time of day (circadian rhythm) affect the body's temperature?
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38. How is pulse best found?
orthostatic hypertension
20-30
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.
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
39. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
hypotension
the lungs
about 1 degree lower than oral temperatures
oximetry
40. Are infants blood pressure low or high?
low
Rhonchi
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Kussmaul's respiration
41. Increased rate and depth with panting and long grunting exhalation. Often seen with patients with acidosis and renal failure.
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42. Alternating rise and fall of the temperature.
+2
intermittent
12-20
arrhythmia
43. Fever above 100.2 F
wheeze
arrhythmia
low BP
pyrexia
44. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
temperature - pulse - respiration - blood pressure - and pain level.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Pulse pressure
Evaporation
45. What patients should not use a glass thermometer orally?
tachycardia
Temperature will remain below 102 degrees with use of hypothermia blanket
Feeble
uncooperative patient - children - combative patients - dementia
46. 2nd stage of fever is?
Axillary.
Hyperventilation
+1
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.
47. An example of a nursing diagnoses
oximetry
Hyperthermia related to infection or excessive heat exposure
Conduction
dyspnea
48. 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
Pedal pulse
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
blood pressure is lowest in the morning. and higher in the afternoone
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
49. Side of neck
Femoral
Korotkoff sounds Phase II Swishing
carotid
Cheyenne-Stokes
50. The maximum pressure exerted on the artery during left ventricular contraction.
Systolic pressure
Temperature will remain below 102 degrees with use of hypothermia blanket
Biot's
blood pressure is lowest in the morning. and higher in the afternoone