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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.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

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. Feel
Korotkoff sounds Phase III: Knocking
Cardiac Output
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
palpate

2. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
It increases to push the blood through more rigid pathways.
Dorsalis pedis
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

3. Healthly adult
Temperature will remain below 102 degrees with use of hypothermia blanket
12-20
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
wheeze

4. High oxygen
shallow or slow breathing
Korotkoff sounds Phase IV: Muffling
hyperoxia
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

5. Risk for prolonged hypertension
Blood pressure increases because there is more volume of blood in the vascular system.
bradypnea
It will also fall
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

6. How does disease increase the body's temperature?
Feeble
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
30-80

7. Normal body temperature ranges?
Stroke Volume
Nursing interventions to reduce fever
Evaporation
97.5 to 99.5

8. How does physical exercise raise the body's temperature?
males have higher bp - until menopause then they are the same
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
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.

9. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Evaporation
arrhythmia
the lungs
Respiration

10. Alternating rise and fall of the temperature.
intermittent
72 bpm
thready
popliteal

11. Groin area
Femoral
Brachial
Korotkoff sounds
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

12. What patients should not use a glass thermometer orally?
raises BP.
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Stroke volume
uncooperative patient - children - combative patients - dementia

13. Average pulse rate for an adult
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
72 bpm
ausculatation
Brachial

14. BP at or lower 90/60.
hypotension
uncooperative patient - children - combative patients - dementia
shallow or slow breathing
higher

15. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
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.
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.
oximeter
12-20

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

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17. 3rd stage of fever?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
about 1 degree higher than oral temperatures
men - African Americans - under a lot of stress - obese

18. Those at risk for hypothermia include
Dorsalis pedis
Pulse pressure
BMR
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.

19. How does emotional stress raise the body's temperature?
absent
stridor
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Hypothermia

20. 2nd stage of fever is?
hypotension
120/70
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.
palpate

21. Stage 2 hypertension
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
Evaporation
raises BP.
^160/^100

22. Absence of breathing
oximetry
apnea
hyperoxia
Diastolic pressure

23. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
temperature - pulse - respiration - blood pressure - and pain level.
Cheyenne-Stokes
Eupnea
Blood pressure increases because there is more volume of blood in the vascular system.

24. 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.
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
hypoxemia
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.
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.

25. Fast - deep respirations with abrupt pauses

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26. Korotkoff sounds Phase I: Tapping
Femoral
systolic pressure indicated by faint - clear sound that gradually grow louder.
140-159/90-99
Evaporation

27. 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.
left Sims position
crackles
orthostatic hypertension
Hypothermia

28. State of insufficient oxygen
hypoxia
It increases to push the blood through more rigid pathways.
higher
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.

29. The average temperature in the older adult
3 in the right lung and 2 lobes in the left
96.5 to 97.5
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.
the blood pressure will rise in order to push the blood along.

30. Bend of knee
cardiac patients or patients who have had rectal surgery.
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
popliteal
stridor

31. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
wheeze
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
dyspnea
Feeble

32. Stress & emotions. BP?
tachycardia
stridor
higher
Cheyenne-Stokes

33. Low oxygen
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.
hypoxia
Kussmaul's respiration
Posterior tibial

34. Korotkoff sounds Ausculatatory gap:
30-80
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
from drug therapy - a neurologic problem or dehydration.
the rate - the rhythm - and volume

35. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Stertor
Posterior tibial
Kussmaul's respiration
the rate - the rhythm - and volume

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

37. When should rectal temperatures NOT be used?
Conduction
cardiac patients or patients who have had rectal surgery.
popliteal
bradycardia

38. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
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.
Cheyenne-Stokes
constant
97.5 to 99.5

39. By measuring the blood pressure you obtain vital info about what?
BMR
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.
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
uncooperative patient - children - combative patients - dementia

40. Strong and regular ( even beats wit moderate force)
+2
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Cardiac Output
30-80

41. Increased rate and depth with panting and long grunting exhalation. Often seen with patients with acidosis and renal failure.

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42. When should rectal temperatures be used?
Cheyenne-Stokes
Hyperventilation
absent
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

43. Slow and shallow breathing - leads to hypoxemia.
Biot's respirations
thready
bradypnea
blood pressure is lowest in the morning. and higher in the afternoone

44. Full and bounding (even beats wit strong force)
+2
Relapsing
+3
bradycardia

45. An example of a nursing diagnoses
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
Hyperthermia related to infection or excessive heat exposure
raises BP.
+1

46. What should you do if you cannot determine BP by ausculation?
pyrogens
popliteal
Sinoatrial node (SA NODE)
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.

47. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
16-20
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.
Korotkoff sounds Phase IV: Muffling
Korotkoff sounds Phase II Swishing

48. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
the blood pressure will rise in order to push the blood along.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

49. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
left Sims position
higher
oximeter
Crisis

50. If the cardiac output falls what will happen to the BP?
It will also fall
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.
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.