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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
Apical
^160/^100
Korotkoff sounds
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

2. Air movemtn causes heat to be transferred from the skin to the air molecules.
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.
the blood pressure will rise in order to push the blood along.
Convection
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.

3. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Pedal pulse
Pons and Medulla of the brainstem
Axillary.
Pulse

4. Enviromental temperature BP?
30-80
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Biot's

5. Alternating rise and fall of the temperature.
intermittent
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.
Diastolic pressure
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

6. Full and bounding (even beats wit strong force)
Conduction
20-30
men - African Americans - under a lot of stress - obese
+3

7. What are the 5 vital signs?
temperature - pulse - respiration - blood pressure - and pain level.
+3
30-80
The pulse rate gradually diminishes from birth to adulthood

8. Adolescent
16-20
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.
carotid
Respiration

9. Side of neck
the rate - the rhythm - and volume
pyrogens
systolic pressure indicated by faint - clear sound that gradually grow louder.
carotid

10. Inside ankle
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Posterior tibial
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.
Korotkoff sounds Phase IV: Muffling

11. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
the lungs
remittent
Systolic pressure
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.

12. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
oximeter
Pulse
Biot's

13. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
from drug therapy - a neurologic problem or dehydration.
Hyperventilation
temperature - pulse - respiration - blood pressure - and pain level.

14. Absence of breathing
about 1 degree higher than oral temperatures
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
BMR
apnea

15. When warm skin touches a cool object - heat is lost to the object.
ausculatation
Biot's
Conduction
temperature - pulse - respiration - blood pressure - and pain level.

16. Diurnal variation BP?
blood pressure is lowest in the morning. and higher in the afternoone
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
hypoxia
cardiac patients or patients who have had rectal surgery.

17. Slow and shallow breathing - leads to hypoxemia.
72 bpm
Korotkoff sounds Phase II Swishing
Pedal pulse
bradypnea

18. How do you measure the apical pulse?
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.
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
Stroke volume
20-30

19. Side of forehead
+1
Temporal
Korotkoff sounds Phase IV: Muffling
30-80

20. The rate at which heat is produced when the body is at rest.
BMR
carotid
16-20
palpate

21. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
arrhythmia
tachycardia
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Vascular resistance drops and the blood pressure decreases

22. 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?
Evaporation
lysis
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
absent

23. What affects does aging do to the blood pressure?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
higher

24. Encourage a large fluid intake - lower room temperature - increase air circulation - remove items of clothes - control or reduce the amount of body activity - carry out physicians orders
120/70
Temperature will remain below 102 degrees with use of hypothermia blanket
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Nursing interventions to reduce fever

25. Lobes in the lungs?
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.
lysis
3 in the right lung and 2 lobes in the left
Conduction

26. Bend of elbow
Brachial
Korotkoff sounds Phase III: Knocking
intermittent
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

27. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
It increases to push the blood through more rigid pathways.
pyrogens
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.
popliteal

28. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
Korotkoff sounds Phase V: Silence
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
hypoxemia
shallow or slow breathing

29. A pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled - causing te blood level of carbon dioxide to fall. this condition is seen after sever exertion - during high levels of anxiety o
stridor
hypotension
Hyperventilation
Temperature will remain below 102 degrees with use of hypothermia blanket

30. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Cardiac Output
higher
72 bpm
Rhonchi

31. Elderly respiration
16-20
popliteal
Blood pressure increases because there is more volume of blood in the vascular system.
Eupnea

32. Increased or rapid breathing results from te presence of fever and a number or diseases. breathing rate increased about 4 breaths for each degree increase in temperature.
Tachypnea
72 bpm
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.
97.5 to 99.5

33. Substances tat cause fever
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.
bradycardia
It will also fall
pyrogens

34. Both strong and weak beats occur within 1 minute
Irregular
Convection
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.
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

35. Elevated temperature
Increases as body tries to remove excess heat
fever
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

36. Sex BP?
males have higher bp - until menopause then they are the same
the rate - the rhythm - and volume
Crisis
Sinoatrial node (SA NODE)

37. People most at risk for hypertension
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.
uncooperative patient - children - combative patients - dementia
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
men - African Americans - under a lot of stress - obese

38. Those at risk for hypothermia include
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.
Korotkoff sounds Phase II Swishing
carotid

39. Taking axillary temperature
Feeble
carotid
BMR
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.

40. Barely palpable
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Cheyenne-Stokes
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Feeble

41. Korotkoff sounds Phase I: Tapping
systolic pressure indicated by faint - clear sound that gradually grow louder.
Apical
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
Temperature will remain below 102 degrees with use of hypothermia blanket

42. What characteristics should be noted when checking the pulse?
Respiration
the rate - the rhythm - and volume
Pedal pulse
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.

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

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44. Does the respiration rate increase or decrease during fever?
Conduction
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Pedal pulse
Increases as body tries to remove excess heat

45. right arm vs. left arm/ arm vs. leg BP?
Korotkoff sounds Phase IV: Muffling
It increases to push the blood through more rigid pathways.
temperature - pulse - respiration - blood pressure - and pain level.
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

46. Obtaining the correct size for a cuff for BP?
It increases to push the blood through more rigid pathways.
+2
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
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

47. BP at or lower 90/60.
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
carotid
hypotension
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

48. Strong and regular ( even beats wit moderate force)
Stroke Volume
+2
popliteal
tachycardia

49. 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.
Axillary.
Hypothermia
fever
Pulse pressure

50. Gas exchange in the blood occurs where?
in the alveoli - tiny thin-walled sacs
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
20-30
120/80

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Measuring Vital Signs

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