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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. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
pyrogens
bradycardia
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Hyperthermia related to infection or excessive heat exposure

2. 3 yr old
20-30
left Sims position
remittent
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. What should you do if you cannot determine BP by ausculation?
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.
in the alveoli - tiny thin-walled sacs
12-20
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

4. Head injury BP?
raises BP.
pyrexia
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.
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.

5. The volume of blood pushed into the aorta per heartbeat.
Posterior tibial
Stroke volume
wheeze
BMR

6. What happens when vasodilation occurs?
Respiration
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.
low BP
Vascular resistance drops and the blood pressure decreases

7. Strong and regular ( even beats wit moderate force)
+2
Rhonchi
higher
wheeze

8. Enviromental temperature BP?
Nursing interventions to reduce fever
Rhonchi
3 in the right lung and 2 lobes in the left
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

9. Measurement of oxygen
Temporal
3 in the right lung and 2 lobes in the left
oximetry
cardiac patients or patients who have had rectal surgery.

10. Breathing is an involuntary automatic function controlled by the respiratory center located where?
hypotension
+3
crackles
Pons and Medulla of the brainstem

11. Korotkoff sounds Ausculatatory gap:
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
men - African Americans - under a lot of stress - obese
left Sims position

12. Substances tat cause fever
pyrogens
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.
men - African Americans - under a lot of stress - obese
Sinoatrial node (SA NODE)

13. Healthly adult
Nursing interventions to reduce fever
96.5 to 97.5
12-20
carotid

14. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
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.
Diastolic pressure
Radial
bradycardia

15. 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.
Relapsing
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.
hypoxemia
Cardiac Output

16. Prehypertension
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
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.
120-139/80-89
low

17. Inside ankle
from drug therapy - a neurologic problem or dehydration.
97.5 to 99.5
Posterior tibial
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

18. Air movemtn causes heat to be transferred from the skin to the air molecules.
140-159/90-99
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Biot's
Convection

19. When should rectal temperatures be used?
Korotkoff sounds Phase III: Knocking
Diaphoresis
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

20. The rate at which heat is produced when the body is at rest.
lysis
BMR
Pedal pulse
shallow or slow breathing

21. Feel
palpate
Pulse pressure
higher
hypotension

22. Top of left foot
Core Temperature
Systolic pressure
Dorsalis pedis
The pulse rate gradually diminishes from birth to adulthood

23. 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
in the alveoli - tiny thin-walled sacs
thready
Temperature will remain below 102 degrees with use of hypothermia blanket
Nursing interventions to reduce fever

24. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
stridor
Crisis
absent
96.5 to 97.5

25. Fever above 100.2 F
Kussmaul's respiration
pyrexia
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
uncooperative patient - children - combative patients - dementia

26. How does physical exercise raise the body's temperature?
Diastolic pressure
about 1 degree higher than oral temperatures
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.
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

27. Elderly respiration
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
16-20
pyrexia
the blood pressure will rise in order to push the blood along.

28. State of insufficient oxygen
72 bpm
20-30
hypoxia
Posterior tibial

29. 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.
the lungs
Diaphoresis
Respiration
remittent

30. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
the lungs
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
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.
remittent

31. Bend of elbow
Brachial
hypoxemia
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
left Sims position

32. Weak and regular (even beats wit poor force)
+1
Kussmaul's respiration
from drug therapy - a neurologic problem or dehydration.
hyperoxia

33. How is shock caused?
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.
hypertension
Brachial
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

34. A normal - relaxed breathing pattern
oximeter
pyrogens
Diaphoresis
Eupnea

35. Absence of breathing
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Pedal pulse
60 to 70 mL
apnea

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. Stage 2 hypertension
wheeze
Respiration
constant
^160/^100

38. Pulse above 100 beats per minute
stridor
Apical
tachycardia
Pedal pulse

39. Stress & emotions. BP?
Korotkoff sounds Phase III: Knocking
+2
Axillary.
higher

40. Elevated temperature
systolic pressure indicated by faint - clear sound that gradually grow louder.
hypoxia
thready
fever

41. 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.
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 deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
hyperoxia
crackles

42. Whats the best position to take a rectal temperature?
left Sims position
low BP
Nursing interventions to reduce fever
uncooperative patient - children - combative patients - dementia

43. 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.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
It will also fall
Irregular
Hypothermia

44. Korotkoff sounds Phase I: Tapping
Hypothermia
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
systolic pressure indicated by faint - clear sound that gradually grow louder.
16-20

45. How should baby's temperature be taken?
Stroke Volume
Axillary.
palpate
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

46. Louder knocking sound that occurs wit each heartbeat
140-159/90-99
Eupnea
Korotkoff sounds Phase III: Knocking
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.

47. Gas exchange in the blood occurs where?
in the alveoli - tiny thin-walled sacs
Acute anxiety stimulate the nervous system - raising the pulse.
Korotkoff sounds Phase II Swishing
pyrexia

48. Side of forehead
Kussmaul's respiration
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.
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Temporal

49. 1st stage of fever is?
Dorsalis pedis
orthostatic hypertension
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
Tachypnea

50. 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?
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
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.
Hypothermia