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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. What should you do if you cannot determine BP by ausculation?
thready
120/70
systolic pressure indicated by faint - clear sound that gradually grow louder.
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.

2. How does increased body temperature increase the pulse?
hyperoxia
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Posterior tibial
It will also fall

3. When warm skin touches a cool object - heat is lost to the object.
palpate
+1
120/70
Conduction

4. 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
lysis
Systolic pressure
It will also fall

5. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
dyspnea
Core Temperature
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.
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.

6. Pulse above 100 beats per minute
carotid
the rate - the rhythm - and volume
fever
tachycardia

7. The difference between the systolic pressure and the diastolic pressure
Pulse pressure
the lungs
Respiration
orthostatic hypertension

8. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Radial
pyrexia
shallow or slow breathing
thready

9. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Posterior tibial
constant
Hypothermia

10. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
+1
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Rhonchi
tachycardia

11. Obtaining the correct size for a cuff for BP?
dyspnea
higher
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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.

12. Air movemtn causes heat to be transferred from the skin to the air molecules.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Convection
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.

13. Prehypertension
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
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
shallow or slow breathing
120-139/80-89

14. Weak and may be irregular
Tachypnea
hypotension
thready
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.

15. A normal - relaxed breathing pattern
Respiration
Eupnea
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.
from drug therapy - a neurologic problem or dehydration.

16. Louder knocking sound that occurs wit each heartbeat
Hyperventilation
Korotkoff sounds Phase III: Knocking
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.
Apical

17. Symptoms of hypoxia
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.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
apnea
Pulse pressure

18. What characteristics should be noted when checking the pulse?
Eupnea
the rate - the rhythm - and volume
the lungs
^160/^100

19. An example of a nursing diagnoses
carotid
blood pressure is lowest in the morning. and higher in the afternoone
+3
Hyperthermia related to infection or excessive heat exposure

20. Absence of breathing
popliteal
apnea
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.
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

21. When should rectal temperatures NOT be used?
bradycardia
hyperoxia
Hyperventilation
cardiac patients or patients who have had rectal surgery.

22. Average pulse rate for an adult
72 bpm
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Irregular
raises BP.

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

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24. 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
Evaporation
12-20
Pedal pulse
pyrexia

25. Korotkoff sounds Phase I: Tapping
Biot's respirations
systolic pressure indicated by faint - clear sound that gradually grow louder.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Dorsalis pedis

26. Whats the best position to take a rectal temperature?
Acute anxiety stimulate the nervous system - raising the pulse.
Rhonchi
left Sims position
uncooperative patient - children - combative patients - dementia

27. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Irregular
Evaporation
120/70
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.

28. Heart
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
Apical
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.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.

29. 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.
left Sims position
the rate - the rhythm - and volume
Cardiac Output
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.

30. Rectal temperature are
apnea
Vascular resistance drops and the blood pressure decreases
dyspnea
about 1 degree higher than oral temperatures

31. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
Cheyenne-Stokes
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Hyperventilation
120/70

32. The temperature of the deep tissues of the body
arrhythmia
pyrogens
Core Temperature
popliteal

33. Sex BP?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
males have higher bp - until menopause then they are the same
hypoxia
palpate

34. How does menstrual cycle and pregnancy raise the body's temperature?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
uncooperative patient - children - combative patients - dementia
Diaphoresis
Biot's

35. 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?
60 to 70 mL
^160/^100
the blood pressure will rise in order to push the blood along.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

36. Pulse lower than 60 beats per minute
Apical
temperature - pulse - respiration - blood pressure - and pain level.
bradycardia
systolic pressure indicated by faint - clear sound that gradually grow louder.

37. Why would patients experience orthostatic hypotenstion?
from drug therapy - a neurologic problem or dehydration.
the rate - the rhythm - and volume
Korotkoff sounds Phase II Swishing
Brachial

38. 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
the lungs
shallow or slow breathing
30-80

39. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Acute anxiety stimulate the nervous system - raising the pulse.
Hypothermia
remittent
Korotkoff sounds

40. Diurnal variation BP?
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.
blood pressure is lowest in the morning. and higher in the afternoone
Biot's respirations
pyrexia

41. Adolescent
It increases to push the blood through more rigid pathways.
Pedal pulse
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.
16-20

42. 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.
crackles
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.
low
Tall - slender people mayy ave a slower pulse rate than short - stout persons

43. When is apicial pulse used?
left Sims position
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
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.
palpate

44. No pulse palpable or heard on ausculation
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
absent
men - African Americans - under a lot of stress - obese
in the alveoli - tiny thin-walled sacs

45. BP at or lower 90/60.
Sinoatrial node (SA NODE)
absent
Diastolic pressure
hypotension

46. 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.
hypoxemia
dyspnea
Stertor
+3

47. Risk for prolonged hypertension
hypotension
+3
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
140-159/90-99

48. Abrupt decline in fever
Crisis
wheeze
intermittent
the rate - the rhythm - and volume

49. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
wheeze
low BP
hypoxia
Kussmaul's respiration

50. What affects does aging do to the respiratory rate?
Radial
fever
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
Biot's