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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. How do you measure the apical pulse?
Korotkoff sounds Phase IV: Muffling
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
BMR
Cheyenne-Stokes

2. How does the time of day (circadian rhythm) affect the body's temperature?

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3. Those at risk for hypothermia include
Kussmaul's respiration
Vascular resistance drops and the blood pressure decreases
Tachypnea
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.

4. By measuring the blood pressure you obtain vital info about what?
Feeble
oximetry
oximeter
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

5. 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
Femoral
Korotkoff sounds Phase IV: Muffling
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.

6. 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.
It increases to push the blood through more rigid pathways.
remittent
60 to 70 mL
hypertension

7. Sex BP?
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
males have higher bp - until menopause then they are the same
30-80
120-139/80-89

8. The difference between the systolic pressure and the diastolic pressure
Pulse pressure
72 bpm
apnea
shallow or slow breathing

9. Fever above 100.2 F
Hypothermia
pyrexia
Korotkoff sounds Phase V: Silence
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

10. 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?
Crisis
Convection
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
Dorsalis pedis

11. Pulse above 100 beats per minute
Respiration
tachycardia
Blood pressure increases because there is more volume of blood in the vascular system.
carotid

12. Lobes in the lungs?
3 in the right lung and 2 lobes in the left
from drug therapy - a neurologic problem or dehydration.
+3
shallow or slow breathing

13. 2nd stage of fever is?
thready
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
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.
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.

14. Stress & emotions. BP?
higher
remittent
^160/^100
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

15. Drop in blood pressure when arising to a standing position.
Core Temperature
orthostatic hypertension
Cheyenne-Stokes
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

16. Barely palpable
Stroke volume
120-139/80-89
cardiac patients or patients who have had rectal surgery.
Feeble

17. Axillary temperature are
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.
Respiration
about 1 degree lower than oral temperatures
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.

18. Feel
16-20
blood pressure is lowest in the morning. and higher in the afternoone
palpate
absent

19. Slow and shallow breathing - leads to hypoxemia.
shallow or slow breathing
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
carotid
bradypnea

20. Healthly adult
Convection
12-20
crackles
60 to 70 mL

21. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
wheeze
popliteal
Cheyenne-Stokes
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

22. 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
hyperoxia
+3
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

23. 3rd stage of fever?
Diastolic pressure
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
stridor
97.5 to 99.5

24. High BP
higher
Hyperventilation
hypertension
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.

25. How does age affect pulse?
12-20
96.5 to 97.5
The pulse rate gradually diminishes from birth to adulthood
97.5 to 99.5

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

27. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
+2
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Stertor
Pulse pressure

28. What happens to the blood if overhydration occurs?
lysis
16-20
Blood pressure increases because there is more volume of blood in the vascular system.
Nursing interventions to reduce fever

29. Absence of breathing
30-80
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Crisis
apnea

30. Groin area
60 to 70 mL
Femoral
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.
Diaphoresis

31. Weak and may be irregular
Pulse pressure
Apical
oximetry
thready

32. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
crackles
about 1 degree lower than oral temperatures
hypoxia

33. Substances tat cause fever
+3
Brachial
pyrogens
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

34. How do drugs affect pulse?
Korotkoff sounds Phase III: Knocking
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
hypotension
hypoxia

35. Elderly respiration
remittent
low
Convection
16-20

36. People most at risk for hypertension
absent
men - African Americans - under a lot of stress - obese
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
Nursing interventions to reduce fever

37. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
Core Temperature
Eupnea
temperature - pulse - respiration - blood pressure - and pain level.
the lungs

38. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
men - African Americans - under a lot of stress - obese
Cheyenne-Stokes
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
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.

39. Side of neck
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.
orthostatic hypertension
carotid
Stroke volume

40. Whats the best position to take a rectal temperature?
left Sims position
60 to 70 mL
Biot's respirations
Apical

41. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
constant
Hyperventilation
Core Temperature
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.

42. When is apicial pulse used?
Convection
Biot's
Radial
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.

43. Normal body temperature ranges?
popliteal
intermittent
97.5 to 99.5
+2

44. When the heart contracts How many mLs of blood is propelled into the aorta?
60 to 70 mL
hypoxia
Kussmaul's respiration
Hyperthermia related to infection or excessive heat exposure

45. Abrupt decline in fever
Kussmaul's respiration
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.
Crisis
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

46. How does increased body temperature increase the pulse?
hyperoxia
Evaporation
120/70
The pulse rate increases at the rate of 7-10 beats for each degree of temperature

47. An example of nursing planning
Temperature will remain below 102 degrees with use of hypothermia blanket
popliteal
Apical
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

48. Average pulse rate for an adult
Convection
Korotkoff sounds
72 bpm
BMR

49. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
Diastolic pressure
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Feeble
males have higher bp - until menopause then they are the same

50. Full and bounding (even beats wit strong force)
+3
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.
carotid
Pedal pulse