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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. Disappearance of sound. (marks diastolic pressure in adults)
Core Temperature
Korotkoff sounds Phase V: Silence
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
absent

2. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
pyrexia
remittent
stridor
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

3. Stress & emotions. BP?
higher
the rate - the rhythm - and volume
Diaphoresis
uncooperative patient - children - combative patients - dementia

4. An example of nursing planning
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.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Biot's respirations
Temperature will remain below 102 degrees with use of hypothermia blanket

5. 3rd stage of fever?
pyrexia
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
constant

6. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
palpate
men - African Americans - under a lot of stress - obese

7. Taking a rectal temperature
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
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 lower than oral temperatures
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.

8. How does physical exercise raise the body's temperature?
crackles
Radial
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.
Systolic pressure

9. Low oxygen
3 in the right lung and 2 lobes in the left
blood pressure is lowest in the morning. and higher in the afternoone
Stroke Volume
hypoxia

10. The pressure wave causing te arterial walls in the vascular system each time the heart contracts to force blood into an already full aorta.
Diastolic pressure
Pulse
thready
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

11. 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
intermittent
Hyperventilation
blood pressure is lowest in the morning. and higher in the afternoone
apnea

12. When warm skin touches a cool object - heat is lost to the object.
orthostatic hypertension
Conduction
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Irregular

13. The temperature falls to normal and then rises again in a repeating pattern.
Hypothermia
hypotension
Relapsing
Conduction

14. Rectal temperature are
the lungs
bradycardia
the rate - the rhythm - and volume
about 1 degree higher than oral temperatures

15. 3 yr old
20-30
fever
left Sims position
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

16. How do you measure the apical pulse?
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
Diastolic pressure
Biot's
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

17. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
Pulse
hypoxemia
wheeze
Convection

18. What patients should not use a glass thermometer orally?
Nursing interventions to reduce fever
Hyperventilation
uncooperative patient - children - combative patients - dementia
thready

19. What should you do if you cannot determine BP by ausculation?
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.
males have higher bp - until menopause then they are the same
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
crackles

20. Full and bounding (even beats wit strong force)
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
higher
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.
+3

21. 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
Hyperthermia related to infection or excessive heat exposure
hypotension
Dorsalis pedis

22. Korotkoff sounds Ausculatatory gap:
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
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
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
Diaphoresis

23. Abrupt decline in fever
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.
Crisis
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
Pulse

24. People most at risk for hypertension
men - African Americans - under a lot of stress - obese
Conduction
pyrexia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

25. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
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.
Tachypnea
Respiration

26. 1st stage of fever is?
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
Axillary.
hypoxemia
Eupnea

27. The average temperature in the older adult
pyrexia
popliteal
Korotkoff sounds
96.5 to 97.5

28. Lobes in the lungs?
remittent
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
3 in the right lung and 2 lobes in the left
Stroke volume

29. Healthly adult
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.
12-20
carotid
oximetry

30. What will happen in febrile stage if temperature is very high or temperature stays for a long amount of time?
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
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.
in the alveoli - tiny thin-walled sacs
orthostatic hypertension

31. Alternating rise and fall of the temperature.
intermittent
Axillary.
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
Dorsalis pedis

32. Average blood pressure should be
3 in the right lung and 2 lobes in the left
palpate
hypertension
120/70

33. Signs and symptoms of shock
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
hypoxia
120-139/80-89

34. Normal body temperature ranges?
It will also fall
constant
systolic pressure indicated by faint - clear sound that gradually grow louder.
97.5 to 99.5

35. Taking axillary 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.
oximetry
Pulse
Eupnea

36. Murmur or swishing sounds that increase as the cuff is deflated
Korotkoff sounds Phase II Swishing
from drug therapy - a neurologic problem or dehydration.
dyspnea
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

37. BP at or lower 90/60.
lysis
pyrexia
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
hypotension

38. Newborn
apnea
cardiac patients or patients who have had rectal surgery.
Temperature will remain below 102 degrees with use of hypothermia blanket
30-80

39. Why would patients experience orthostatic hypotenstion?
Korotkoff sounds
from drug therapy - a neurologic problem or dehydration.
Rhonchi
Increases as body tries to remove excess heat

40. How is pulse best found?
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.
blood pressure is lowest in the morning. and higher in the afternoone
remittent
^160/^100

41. A sudden change or muffling of the sound. (indicates diastolic pressure in children and some adults)
Feeble
hyperoxia
Korotkoff sounds Phase IV: Muffling
Blood pressure increases because there is more volume of blood in the vascular system.

42. Drop in blood pressure when arising to a standing position.
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.
orthostatic hypertension
raises BP.
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

43. Air movemtn causes heat to be transferred from the skin to the air molecules.
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Convection
the rate - the rhythm - and volume

44. When is apicial pulse used?
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
palpate
pyrexia
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.

45. How does menstrual cycle and pregnancy raise the body's temperature?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
from drug therapy - a neurologic problem or dehydration.
Core Temperature

46. Top of left foot
3 in the right lung and 2 lobes in the left
wheeze
Dorsalis pedis
Feeble

47. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
blood pressure is lowest in the morning. and higher in the afternoone
It increases to push the blood through more rigid pathways.
+3
Biot's

48. Slow and shallow breathing - leads to hypoxemia.
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
constant
120-139/80-89
bradypnea

49. How cardiac contractions are normally initiated by the electrical impules emerging from what?
Core Temperature
from drug therapy - a neurologic problem or dehydration.
Sinoatrial node (SA NODE)
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

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

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Measuring Vital Signs

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