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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. Prehypertension
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
120-139/80-89
Vascular resistance drops and the blood pressure decreases
Respiration

2. An example of a nursing diagnoses
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
Diastolic pressure
shallow or slow breathing
Hyperthermia related to infection or excessive heat exposure

3. Pulse lower than 60 beats per minute
16-20
Systolic pressure
bradycardia
about 1 degree lower than oral temperatures

4. Obtaining the correct size for a cuff for BP?
left Sims position
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
remittent
Blood pressure increases because there is more volume of blood in the vascular system.

5. Substances tat cause fever
Apical
72 bpm
pyrogens
Korotkoff sounds Phase V: Silence

6. Alternating rise and fall of the temperature.
tachycardia
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
intermittent
97.5 to 99.5

7. How do emotions increase the pulse rate?
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Acute anxiety stimulate the nervous system - raising the pulse.
Core Temperature
Convection

8. Blood pressure for any adult should be no higher than
Hyperthermia related to infection or excessive heat exposure
120/80
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Crisis

9. 2nd stage of fever is?
It increases to push the blood through more rigid pathways.
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.
Irregular
Biot's

10. When should rectal temperatures NOT be used?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
3 in the right lung and 2 lobes in the left
cardiac patients or patients who have had rectal surgery.
Radial

11. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
Acute anxiety stimulate the nervous system - raising the pulse.
oximeter
about 1 degree higher than oral temperatures

12. Are infants blood pressure low or high?
hypoxia
Dorsalis pedis
Crisis
low

13. How do drugs affect pulse?
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
intermittent
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

14. How does size affect pulse?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
hypertension
3 in the right lung and 2 lobes in the left
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.

15. 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
Pulse pressure
20-30
Tall - slender people mayy ave a slower pulse rate than short - stout persons

16. When the heart contracts How many mLs of blood is propelled into the aorta?
Pulse
60 to 70 mL
It increases to push the blood through more rigid pathways.
uncooperative patient - children - combative patients - dementia

17. High oxygen
higher
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Convection
hyperoxia

18. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
systolic pressure indicated by faint - clear sound that gradually grow louder.
20-30
wheeze
Cheyenne-Stokes

19. Head injury BP?
raises 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.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
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.

20. No pulse palpable or heard on ausculation
Tachypnea
absent
Temperature will remain below 102 degrees with use of hypothermia blanket
Cheyenne-Stokes

21. The temperature of the deep tissues of the body
97.5 to 99.5
Core Temperature
60 to 70 mL
140-159/90-99

22. Average pulse rate for an adult
72 bpm
in the alveoli - tiny thin-walled sacs
Brachial
The pulse rate gradually diminishes from birth to adulthood

23. What happens to the blood if overhydration occurs?
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.
Blood pressure increases because there is more volume of blood in the vascular system.
palpate

24. Disappearance of sound. (marks diastolic pressure in adults)
Korotkoff sounds Phase V: Silence
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.
Apical
Pulse pressure

25. 3rd stage of fever?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
thready
Evaporation
Respiration

26. A normal - relaxed breathing pattern
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.
96.5 to 97.5
Eupnea
Cheyenne-Stokes

27. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
140-159/90-99
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
dyspnea
stridor

28. By measuring the blood pressure you obtain vital info about what?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
carotid
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

29. People most at risk for hypertension
Crisis
Posterior tibial
men - African Americans - under a lot of stress - obese
Sinoatrial node (SA NODE)

30. 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.
Systolic pressure
pyrexia
blood pressure is lowest in the morning. and higher in the afternoone
hypoxemia

31. Slow and shallow breathing - leads to hypoxemia.
+1
bradypnea
about 1 degree lower than oral temperatures
Relapsing

32. When warm skin touches a cool object - heat is lost to the object.
Conduction
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
hypoxia
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.

33. When should rectal temperatures be used?
20-30
lysis
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 pulse rate increases at the rate of 7-10 beats for each degree of temperature

34. Side of forehead
Temporal
Diastolic pressure
Irregular
Sinoatrial node (SA NODE)

35. BP at or lower 90/60.
16-20
hypotension
Eupnea
Pulse pressure

36. The average temperature in the older adult
Evaporation
lysis
oximetry
96.5 to 97.5

37. Gradual return to a normal temperature
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Diastolic pressure
Cardiac Output
lysis

38. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
30-80
shallow or slow breathing
^160/^100
12-20

39. Barely palpable
low
Feeble
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Hyperthermia related to infection or excessive heat exposure

40. Absence of breathing
apnea
Stertor
Relapsing
120-139/80-89

41. Air movemtn causes heat to be transferred from the skin to the air molecules.
wheeze
16-20
Convection
120/80

42. Taking a rectal temperature
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
remittent
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
in the alveoli - tiny thin-walled sacs

43. What affects does aging do to the blood pressure?
hypoxia
Korotkoff sounds Phase III: Knocking
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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.

44. Full and bounding (even beats wit strong force)
+3
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Korotkoff sounds Phase II Swishing
16-20

45. Murmur or swishing sounds that increase as the cuff is deflated
Korotkoff sounds Phase II Swishing
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
cardiac patients or patients who have had rectal surgery.

46. When is apicial pulse used?
crackles
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.
120/80
Blood pressure increases because there is more volume of blood in the vascular system.

47. Those at risk for hypothermia include
Hyperventilation
lysis
low
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.

48. The rate at which heat is produced when the body is at rest.
Pons and Medulla of the brainstem
BMR
Diastolic pressure
30-80

49. What affects does aging do to the heart rate?

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50. An example of nursing planning
Pulse
+3
Temperature will remain below 102 degrees with use of hypothermia blanket
Hyperthermia related to infection or excessive heat exposure

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Measuring Vital Signs

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