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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 emotions increase the pulse rate?
Acute anxiety stimulate the nervous system - raising the pulse.
Cheyenne-Stokes
bradypnea
20-30

2. 3rd stage of fever?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
absent
Korotkoff sounds Phase V: Silence
3 in the right lung and 2 lobes in the left

3. 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
Nursing interventions to reduce fever
hypotension
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Cardiac Output

4. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
low
crackles
Korotkoff sounds Phase V: Silence
Diastolic pressure

5. When should rectal temperatures NOT be used?
carotid
cardiac patients or patients who have had rectal surgery.
low BP
stridor

6. Air movemtn causes heat to be transferred from the skin to the air molecules.
140-159/90-99
carotid
Convection
Cheyenne-Stokes

7. Risk for prolonged hypertension
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
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
fever
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.

8. Abnormal - nonmusical sound heard on ausculation of the lungs during inspiration; also called rales. Sound like hair rubbed between the fingers next to the ears.
Korotkoff sounds
120-139/80-89
72 bpm
crackles

9. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Pulse
Apical
96.5 to 97.5
Korotkoff sounds

10. Breathing is an involuntary automatic function controlled by the respiratory center located where?
Pons and Medulla of the brainstem
stridor
about 1 degree lower than oral temperatures
Nursing interventions to reduce fever

11. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
Femoral
Tall - slender people mayy ave a slower pulse rate than short - stout persons
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.

12. How does emotional stress raise the body's temperature?
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.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
The emotions increase hormone secretion - and the body activities required for this increase heat production.
+2

13. The difference between the systolic pressure and the diastolic pressure
Axillary.
20-30
Pulse pressure
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

14. Gas exchange in the blood occurs where?
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
Hypothermia
orthostatic hypertension
in the alveoli - tiny thin-walled sacs

15. BP at or lower 90/60.
+1
hypotension
bradypnea
Crisis

16. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
Hyperthermia related to infection or excessive heat exposure
Korotkoff sounds Phase III: Knocking
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.
It increases to push the blood through more rigid pathways.

17. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
higher
Respiration
+2
the lungs

18. Lobes in the lungs?
intermittent
Stertor
Stroke volume
3 in the right lung and 2 lobes in the left

19. Slow and shallow breathing - leads to hypoxemia.
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 lungs
The emotions increase hormone secretion - and the body activities required for this increase heat production.
bradypnea

20. How do you measure the apical pulse?
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.
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
Sinoatrial node (SA NODE)
120-139/80-89

21. Axillary temperature are
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
about 1 degree lower than oral temperatures
males have higher bp - until menopause then they are the same
shallow or slow breathing

22. Stress & emotions. BP?
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
higher
16-20
60 to 70 mL

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

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24. When is apicial pulse used?
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.
96.5 to 97.5
Pulse
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. 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.
Diaphoresis
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
Brachial

26. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
Convection
Stertor
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
low BP

27. Strong and regular ( even beats wit moderate force)
16-20
+2
crackles
ausculatation

28. What affects does aging do to the respiratory rate?
Stroke volume
96.5 to 97.5
Korotkoff sounds
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

29. How does external respiration occur?
Tall - slender people mayy ave a slower pulse rate than short - stout persons
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
Hyperthermia related to infection or excessive heat exposure
Cheyenne-Stokes

30. How does menstrual cycle and pregnancy raise the body's temperature?
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Stroke volume
Irregular
Nursing interventions to reduce fever

31. Heart
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
Korotkoff sounds
Korotkoff sounds Phase II Swishing

32. 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.
constant
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.
Stroke Volume
remittent

33. Hearing
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Stroke Volume
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
ausculatation

34. Normal body temperature ranges?
97.5 to 99.5
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
Irregular
Stroke Volume

35. Disappearance of sound. (marks diastolic pressure in adults)
It will also fall
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
carotid
Korotkoff sounds Phase V: Silence

36. Prehypertension
Pons and Medulla of the brainstem
Temporal
120-139/80-89
stridor

37. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Stroke Volume
temperature - pulse - respiration - blood pressure - and pain level.
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Evaporation

38. Signs and symptoms of shock
palpate
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
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
Convection

39. 2nd stage of fever is?
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.
Hyperventilation
60 to 70 mL
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.

40. Korotkoff sounds Phase I: Tapping
+3
Evaporation
30-80
systolic pressure indicated by faint - clear sound that gradually grow louder.

41. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
The pulse rate gradually diminishes from birth to adulthood
12-20
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
shallow or slow breathing

42. The exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing.
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
3 in the right lung and 2 lobes in the left
about 1 degree higher than oral temperatures
Respiration

43. Obtaining the correct size for a cuff for BP?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
Radial
Pedal pulse
^160/^100

44. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
popliteal
males have higher bp - until menopause then they are the same
palpate
arrhythmia

45. What patients should not use a glass thermometer orally?
Axillary.
Eupnea
Nursing interventions to reduce fever
uncooperative patient - children - combative patients - dementia

46. Enviromental temperature BP?
lysis
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
Radial
Convection

47. Abrupt decline in fever
Crisis
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Sinoatrial node (SA NODE)
Cardiac Output

48. Fever above 100.2 F
pyrexia
thready
120-139/80-89
96.5 to 97.5

49. The temperature of the deep tissues of the body
Core Temperature
Diastolic pressure
Temperature will remain below 102 degrees with use of hypothermia blanket
96.5 to 97.5

50. How should baby's temperature be taken?
Axillary.
apnea
Dorsalis pedis
Femoral

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Measuring Vital Signs

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