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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. Stage 2 hypertension
Korotkoff sounds Phase II Swishing
^160/^100
hypoxia
about 1 degree lower than oral temperatures

2. What patients should not use a glass thermometer orally?
Axillary.
Brachial
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
uncooperative patient - children - combative patients - dementia

3. Excessive sweat production
Diaphoresis
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Pedal 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

4. Blood pressure for any adult should be no higher than
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Eupnea
120/80
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

5. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
Axillary.
ausculatation
the blood pressure will rise in order to push the blood along.
systolic pressure indicated by faint - clear sound that gradually grow louder.

6. Average blood pressure should be
remittent
Tall - slender people mayy ave a slower pulse rate than short - stout persons
120/70
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

7. Risk for prolonged hypertension
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
temperature - pulse - respiration - blood pressure - and pain level.
Apical
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

8. 1st stage of fever is?
Tachypnea
Biot's respirations
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
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.

9. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Temperature will remain below 102 degrees with use of hypothermia blanket
hypoxia
20-30
Rhonchi

10. Weak and regular (even beats wit poor force)
bradycardia
popliteal
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
+1

11. Stage 1 hypertension
The emotions increase hormone secretion - and the body activities required for this increase heat production.
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.
140-159/90-99
pyrexia

12. Feel
palpate
Biot's respirations
+3
Diaphoresis

13. Does the respiration rate increase or decrease during fever?
Increases as body tries to remove excess heat
20-30
hyperoxia
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

14. Head injury BP?
raises BP.
hypoxia
hypoxemia
Respiration

15. The temperature of the deep tissues of the body
bradypnea
Korotkoff sounds Phase III: Knocking
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Core Temperature

16. Groin area
Nursing interventions to reduce fever
Korotkoff sounds Phase III: Knocking
Femoral
Increases as body tries to remove excess heat

17. Air movemtn causes heat to be transferred from the skin to the air molecules.
20-30
Convection
Cheyenne-Stokes
wheeze

18. When should rectal temperatures NOT be used?
cardiac patients or patients who have had rectal surgery.
shallow or slow breathing
12-20
males have higher bp - until menopause then they are the same

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

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20. Obtaining the correct size for a cuff for BP?
Eupnea
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Rhonchi
Korotkoff sounds Phase II Swishing

21. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
higher
constant
60 to 70 mL
Evaporation

22. How does emotional stress raise the body's temperature?
systolic pressure indicated by faint - clear sound that gradually grow louder.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
in the alveoli - tiny thin-walled sacs

23. Korotkoff sounds Ausculatatory gap:
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Pons and Medulla of the brainstem
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

24. Axillary temperature are
+2
males have higher bp - until menopause then they are the same
Acute anxiety stimulate the nervous system - raising the pulse.
about 1 degree lower than oral temperatures

25. Both strong and weak beats occur within 1 minute
3 in the right lung and 2 lobes in the left
96.5 to 97.5
Systolic pressure
Irregular

26. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
96.5 to 97.5
Korotkoff sounds Phase II Swishing
Korotkoff sounds
oximeter

27. Symptoms of hypoxia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
pyrexia
Korotkoff sounds Phase III: Knocking
Dorsalis pedis

28. How does external respiration occur?
hypertension
Cheyenne-Stokes
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
systolic pressure indicated by faint - clear sound that gradually grow louder.

29. Whats the best position to take 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
hyperoxia
Dorsalis pedis
left Sims position

30. The average temperature in the older adult
shallow or slow breathing
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Pulse
96.5 to 97.5

31. No pulse palpable or heard on ausculation
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Conduction
Korotkoff sounds Phase III: Knocking
absent

32. How is pulse best found?
left Sims position
bradypnea
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.
Conduction

33. 2nd stage of fever is?
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.
+2
Biot's
systolic pressure indicated by faint - clear sound that gradually grow louder.

34. How does size affect pulse?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Pulse pressure
arrhythmia
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

35. State of insufficient oxygen
carotid
hypoxia
from drug therapy - a neurologic problem or dehydration.
96.5 to 97.5

36. High BP
hypertension
Femoral
low BP
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.

37. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Pulse pressure
bradycardia
Stertor
Rhonchi

38. An example of nursing planning
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Temperature will remain below 102 degrees with use of hypothermia blanket
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.
Tall - slender people mayy ave a slower pulse rate than short - stout persons

39. Absence of breathing
apnea
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 higher than oral temperatures
Convection

40. 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
blood pressure is lowest in the morning. and higher in the afternoone
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.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

41. Are infants blood pressure low or high?
intermittent
120/70
Nursing interventions to reduce fever
low

42. 3rd stage of fever?
Korotkoff sounds Phase II Swishing
hypoxia
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.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

43. 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.
Cardiac Output
16-20
Stertor
hypoxemia

44. Measurement of oxygen
intermittent
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
systolic pressure indicated by faint - clear sound that gradually grow louder.
oximetry

45. Fever above 100.2 F
Diaphoresis
pyrexia
Respiration
Irregular

46. What affects does aging do to the respiratory rate?
stridor
from drug therapy - a neurologic problem or dehydration.
Tachypnea
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

47. Bend of elbow
Brachial
Feeble
^160/^100
oximetry

48. 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.
Hypothermia
Pulse pressure
cardiac patients or patients who have had rectal surgery.
30-80

49. Korotkoff sounds Phase I: Tapping
pyrexia
systolic pressure indicated by faint - clear sound that gradually grow louder.
Pedal pulse
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

50. Diurnal variation BP?
ausculatation
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
left Sims position
blood pressure is lowest in the morning. and higher in the afternoone