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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. Average pulse rate for an adult
BMR
72 bpm
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
16-20

2. Strong and regular ( even beats wit moderate force)
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
+2
bradycardia
hyperoxia

3. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
temperature - pulse - respiration - blood pressure - and pain level.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
popliteal

4. Healthly adult
Stroke Volume
3 in the right lung and 2 lobes in the left
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.
12-20

5. How is pulse best found?
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Radial
Eupnea
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.

6. What happens when vasodilation occurs?
Nursing interventions to reduce fever
Vascular resistance drops and the blood pressure decreases
Blood pressure increases because there is more volume of blood in the vascular system.
popliteal

7. Head injury BP?
Pons and Medulla of the brainstem
raises BP.
Kussmaul's respiration
Blood pressure increases because there is more volume of blood in the vascular system.

8. 3rd stage of fever?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
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
about 1 degree lower than oral temperatures
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.

9. How should respirations be counted?
Posterior tibial
Relapsing
Irregular
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

10. Stage 1 hypertension
Feeble
120/80
Stroke Volume
140-159/90-99

11. How do emotions increase the pulse rate?
140-159/90-99
Acute anxiety stimulate the nervous system - raising the pulse.
97.5 to 99.5
Temperature will remain below 102 degrees with use of hypothermia blanket

12. Taking a rectal temperature
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.
Feeble
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
30-80

13. How do you measure the apical pulse?
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
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
120/80

14. Obtaining the correct size for a cuff for BP?
intermittent
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Eupnea
Stroke volume

15. Newborn
popliteal
30-80
the rate - the rhythm - and volume
^160/^100

16. If the cardiac output falls what will happen to the BP?
96.5 to 97.5
Convection
It will also fall
temperature - pulse - respiration - blood pressure - and pain level.

17. What affects does aging do to the blood pressure?
hypoxemia
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
crackles
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

18. A normal - relaxed breathing pattern
Eupnea
16-20
30-80
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

19. Hearing
ausculatation
Radial
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.
apnea

20. Elderly respiration
120/80
Korotkoff sounds Phase III: Knocking
absent
16-20

21. What affects does aging do to the respiratory rate?
wheeze
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
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

22. Side of neck
Blood pressure increases because there is more volume of blood in the vascular system.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Axillary.
carotid

23. What are the 5 vital signs?
Conduction
Radial
temperature - pulse - respiration - blood pressure - and pain level.
palpate

24. Disappearance of sound. (marks diastolic pressure in adults)
popliteal
low
about 1 degree lower than oral temperatures
Korotkoff sounds Phase V: Silence

25. Feel
It will also fall
Sinoatrial node (SA NODE)
palpate
hypotension

26. Does the respiration rate increase or decrease during fever?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Increases as body tries to remove excess heat
Dorsalis pedis
hypoxia

27. Bend of knee
lysis
Conduction
popliteal
shallow or slow breathing

28. Measurement of oxygen
Femoral
Hyperthermia related to infection or excessive heat exposure
oximetry
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

29. Why would patients experience orthostatic hypotenstion?
140-159/90-99
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
from drug therapy - a neurologic problem or dehydration.
20-30

30. High oxygen
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
hyperoxia
blood pressure is lowest in the morning. and higher in the afternoone
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.

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

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32. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
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.
palpate
Pulse
remittent

33. Heart
Stroke volume
Relapsing
Apical
crackles

34. 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.
Cardiac Output
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Stroke volume
oximetry

35. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
hypoxia
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Axillary.

36. Prehypertension
Hypothermia
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
120-139/80-89
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

37. When should rectal temperatures be used?
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
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
hypotension

38. When should rectal temperatures NOT be used?
+3
men - African Americans - under a lot of stress - obese
It increases to push the blood through more rigid pathways.
cardiac patients or patients who have had rectal surgery.

39. Axillary temperature are
Core Temperature
about 1 degree lower than oral temperatures
temperature - pulse - respiration - blood pressure - and pain level.
oximetry

40. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
Sinoatrial node (SA NODE)
in the alveoli - tiny thin-walled sacs
the blood pressure will rise in order to push the blood along.
Core Temperature

41. 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?
+1
arrhythmia
Hypothermia
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

42. Korotkoff sounds Ausculatatory gap:
hypertension
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
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.

43. The maximum pressure exerted on the artery during left ventricular contraction.
Sinoatrial node (SA NODE)
tachycardia
Systolic pressure
hypoxia

44. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Systolic pressure
Korotkoff sounds Phase IV: Muffling
Convection
hypotension

45. The average temperature in the older adult
Hyperthermia related to infection or excessive heat exposure
Feeble
96.5 to 97.5
Respiration

46. How does size affect pulse?
96.5 to 97.5
Tall - slender people mayy ave a slower pulse rate than short - stout persons
The pulse rate gradually diminishes from birth to adulthood
Feeble

47. How does age affect pulse?
ausculatation
Crisis
hypertension
The pulse rate gradually diminishes from birth to adulthood

48. Gas exchange in the blood occurs where?
in the alveoli - tiny thin-walled sacs
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
It will also fall
Korotkoff sounds Phase III: Knocking

49. How does emotional stress raise the body's temperature?
The emotions increase hormone secretion - and the body activities required for this increase heat production.
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.
120/70
the lungs

50. Normal body temperature ranges?
Apical
97.5 to 99.5
the lungs
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.