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94 Cards in this Set

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afebrile
without fever; a condition in which the body temperature is not elevated
apnea
absence of breathing
blood pressure
force of blood against arterial walls
bradycardia
slow heart rate; below 60 bpm
bradypnea
slow breathing rate; < 10 breaths per minute
diastolic pressure
least amount of pressure exerted on arterial walls, which occurs when the heart is at rest between ventricular contractions
dyspnea
difficult or labored breathing; rapid/shallow respirations, appears anxious
dysrhythmia
irregular pattern of beats; 3 types: Bisferiens, Pulsus Alternans; Bigeminal (premature contractions)
eupnea
normal respiration; adults 12-20 breaths/min
febrile
fever; condition in which the body temperature is elevated
fever
an elevated body temperature above normal; synonym is pyrexia
hypertension
blood pressure elevated above the upper limit of normal; > 140 systolic or > 90 diastolic
hypotension
blood pressure below the lower limit of normal; systolic < 90
hypothermia
low body temperature; < 93.2 * F usually means death
Korotkoff sounds
series of sounds that correspond to changes in blood flow through an artery as pressure is released
orthopnea
type of dyspnea in which breathing is easier when the patient sits or stands
orthostatic hypotension
a temporary drop in blood pressure associated when assuming an upright position; synonym is postural hypotension
pulse
wave produced in the wall of an artery with each beat of the heart
pulse deficit
the difference between the apical pulse and the radial pulse rates
pulse pressure
the difference between the systolic and diastolic pressure
respiration
gas exchange between the atmospheric air in the alveoli and blood in the capillaries
systolic pressure
highest point of pressure on the arterial walls when the ventricles contract
tachycardia
rapid heart rate; adults 100-180 beats/min
tachypnea
rapid breathing rate; > 24 breaths/min
temperature
refers to the hotness or coldness of a substance
vital signs
consists of temperature, pulse, respiration and blood pressure; synonym is cardinal signs
Hyperpyrexia
fever => 41* C (105.9* F)
Remittent Fever
the body temperature fluctuates several degrees more than 2* C (3.6* F) above normal but does not reach normal between fluctuations
Stroke Volume
the quantity of blood forced out of the left ventricle with each contraction
Cardiac Output
the volume of blood pumped per minute. Calc: Cardiac Output=Stroke Volume x Heart Rate. Healthy Adult Avg = 3.5 to 8.0 L/min
Pulmonary Ventilation
movement of air into and out of the lungs
Hyperventilation
condition in which there is more than the normal amount of air entering and leaving the lungs; increased rate and depth
Crackles
fine crackling sounds made as air moves through wet secretions in the lungs
Convection
the dissemination of heat by motion between areas of unequal density; ie. fan blowing cool air across warm body
Relapsing Fever
the body temperature returns to normal for at least a day, but then the fever returns
Inspiration
act of breathing in; synonym-inhalation
External Respiration
the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood
Bradypnea
slow rate of breathing; < 10 breaths/minute
Radiation
the diffusion of heat by electromagnet waves; ie. uncovered body gives off heat waves
Evaporation
the conversion of a liquid to a vapor; ie. sweat vaporizing
Intermittent fever
body temperature that alternates between fever and normal or subnormal temperature
Expiration
act of breathing in; synonym-exhalation
Internal Respiration
the exchange of oxygen and carbon dioxide between the circulation blood and the tissue cells
Cheyne-Stokes Respirations
alternating periods of deep, rapid breathing followed by periods of apnea
Biot's Respirations
varying depth and rate of breathing, followed by periods of apnea
Conduction
the transfer of heat to another object during direct contact; ie. body transfer heat to ice pack melting it
Stertorous Respirations
noisy respirations
Wheeze
continuous, high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages
Circadian Rhythm
rhythm that completes a full cycle every 24 hours; i.e. body temperature and blood pressure
Pyrexia
elevation above the upper limit of normal body temperature 38* C - 40.9* C (100.4* F - 105.7* F); synonym - fever
Hypoventilation
decreased rate of depth of air movement into lungs
Kussmaul Respirations
an extreme rate and depth of breathing
Stridor
harsh, high-pitched sounds usually heard on inspiration when upper airways become narrowed
Gurgles (Sonorous Wheezes)
continuous sounds that are audible in expiration or inspiration, or both; formally called rhonchi
List the factors affecting affecting temperature
circadian rhythms, age, gender, stress & environmental temperatures
Identify normal temperatures: Oral, Rectal, Axillary, Tympanic & Skin
Oral: 37.0* C / 98.6* F
Rectal: 37.5* C / 99.5* F
Axillary: 36.5* C / 97.6* F
Tympanic: 37.5* C / 99.5* F
Skin: 34.4* C / 94.0* F
Identify the methods for obtaining temperature
Oral, Rectal, Axillary, Tympanic & Skin
Identify the effects of fever
loss of appetite, headache, hot, dry skin, flushed face, thirst, malaise. Young children or people with high fevers might experience seizures or delirium. Watch for dehydration, decreased urinary output & rapid heart rate.
Describe the methods used to reduce a fever
Antipyretic drugs (aspirin/acetaminophen) lower the elevated set point regulated by the hypothalamus. Antibiotics fight bacterial infection reducing fever. Other intervention: cool sponge baths, cool packs & cooling blankets.
Describe when taking an oral temperature is contraindicated
unconscious, seizure-prone patients, infants & young children, diseases of the oral cavity, after surgery of nose/mouth, after hot/cold food/fluids, within 30 min. of smoking or chewing gum, nasal oxygen or oxygen by mask.
List the factors affecting pulse
activity, medications, emotions, pain, heat & cold, disease processes.
List & describe where each of the peripheral pulse sites are located.
Temporal - temple
Carotid - lateral to cricoid cartilage
Brachial - inside of elbow
Radial - on anterior side of wrist above thumb
Femoral - midway between symphysis pubis and anterior superior iliac spine
Popliteal - back of the knee
Dorsalis Pedis - top of the foot
Posterior tibial - inner ankle between the ankle bone and the achilles tendon
Identify what is meant by pulse rate
the number of pulsations felt over a peripheral artery or heard over the apex of the heart in 1 minute.
Identify what is meant by pulse amplitude and quality
amplitude describes the quality of pulse in terms of fullness and reflects the strength of left ventricular contraction.
Identify what is meant by pulse rhythm
the pattern of the pulsations and the pauses between them.
List the factors affecting respirations
exercise, respiratory and cardiovascular disease, alterations in fluid, electrolyte, and acid-base balances, medications, trauma, infection, pain, emotions.
What is the difference between internal and external respiration?
internal is the exchange of gases between circulating blood and tissue cells, external is the exchange of gases between the alveoli and the circulating blood
List the factors affecting blood pressure
age, circadian rhythm, gender, food intake, exercise, weight, emotional state, body position, race, drugs/medications
What are the different ways in which a blood pressure can be obtained?
Sphygmomanometer,
Noninvasive Blood Pressure Monitors,
Doppler Ultrasound,
Direct Electronic Measurement
Explain the physiologic process involved in homeostatic regulation of temperature
it is maintained by the thermoregulatory center in the hypothalamus. It receives msgs from thermal receptors, compares it with its temperature set & initiates responses to conserve heat or increase heat loss.
Explain the physiologic process involved in pulse
pulse is regulated by the autonomic nervous system through the cardiac sinoatrial (SA) node. Parasympathetic stimulation decreases heart rate, sympathetic stimulation increases heart rate & force of contraction.
Explain the physiologic processes involved in homeostatic regulation of respirations
there are several: pulmonary ventilation is movement of air in and out of the lungs, inspiration is the act of breathing in, expiration is the act of breathing out. Including the exchange of Oxygen & CO2 between alveoli & blood as well as blood and tissue cells.
Identify sites for assessing blood pressure
Brachial artery and Popliteal artery are most common
What is the normal range for pulse?
60-100 bpm in adults
What is considered normal blood pressure
< 120 Systolic & < 80 Diastolic
Provide information to patient regarding taking temperature at home.
Use glass therm., dig therm., single-use disp.,or tape. When taking orally at least 30 min after eat/drink/smoke/chewing gum. Children & infants take temp at axilla. Shake liquid down to below normal, long mark 1 degree, small marks 2/10 degree. Place therm. under tongue 2-3 minutes, no talking. Read & call if > 100 or concerned. Wash therm w warm soapy water, dry & store clean/dry area. Soak in 70% isopropyl alcohol if several members of family using.
Provide information to patients taking pulse at home.
Take pulse prior to medications/exercise. Take within site of clock w second hand. W light pressure place middle 3 fingers below wrist at outside of arm. Locate pulse and count for 60 seconds. Record pulse.
Provide information to patient on taking blood pressure at home.
Take blood pressure once a week. Use a home blood-pressure monitoring device or mechanical device. If home device used, assure proper cuff size & parts working properly. Take bp while seated & arm supported on firm surface. Record results.
An elevation of the body temperature above normal is labeled
a. Fever
b. Hypothermia
c. Hypertension
d. Afebrile
A
Fever is elevation of body temp. Hypothermia is low body temp. Hypertension is elevated blood pressure. Afebrile is no elevation in body temperature.
For which of the following patients would you use an oral thermometer?
a. 6-month-old infant
b. Patient receiving oxygen therapy by mask
c. 42-year-old healthy woman
d. Unconscious patient
C
Oral thermometers are contraindicated in infants patients receiving oxygen and unconscious patients.
Insertion of a rectal thermometer may cause a potentially harmful condition. This condition is
a. An increase in heart rate
b. A decrease in heart rate
c. An involuntary loss of stool
d. An increase in respirations
B
This may stimulate the vagus nerve which would decrease heart rate. This may be potentially harmful for patients with cardiac problems.
While taking an adult patient's pulse, a student finds the rate to be 140 beats/min. What should the student do next?
a. check the pulse again in 2 hours
b. check the blood pressure
c. record the information
d. report the rate
D
A rate of 140 beats/min in an adults is an abnormal pulse and should be reported to instructor or nurse in charge of patient.
A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find
a. An increase in the pulse rate
b. A decrease in body temperature
c. A decrease in blood pressure
d. An increase in body temperature
A
The pulse often increases when experiencing pain. Pain does not affect body temp & may increase (not decrease) blood pressure
What equipment is necessary to assess the apical pulse?
a. Sphygmomanometer
b. Electronic thermometer
c. Stethoscope
d. Doppler apparatus
C
The apical pulse can only be listened to with a stethoscope
The difference between the apical and radial pulse rates is called the
a. Pulse Deficit
b. Pulse Amplitude
c. Ventricular Rhythm
D. Heart Arrhythmia
A
The other names are given to volume and rhythm of pulse
The normal respiratory rate in adults is considered to be
a. 1-6 breaths per minute
b. 12-20
c. 60-80
d. 100-120
B
A patient is having dyspnea. What would the nurse do first?
a. Remove pillows from under the head.
b. Elevate the head of the bed
c. Elevate the food of the bed
d. Take the blood pressure
B
Dyspnea is difficult resp. Elevating head allows abdominal organs to descend allowing greater room for lung expansion.
What does the blood pressure measure?
a. flow of blood through the circulation
b. force of blood against arterial walls
c. force of blood against venous walls
d. flow of blood through the heart
B
With aging, blood pressure is often higher due to
a. loss of muscle mass
b. changes in exercise and diet
c. decreased peripheral resistance
d. decreased elasticity in arterial walls
D
Elasticity is decreased contributing to elevated blood pressure. Other responses may contribute to changes but not physiologically due to age.
A patient has a blood pressure reading of 130/90 m Hg when visiting a clinic. The nurse would recommend
a. Follow-up measurements of blood pressure
b. Immediate treatment by a physician
c. Nothing, because the nurse considers this reading is due to anxiety
d. a change in diet and exercise
A
A single elevated reading is not significant, but should be checked again over time to determine if hypertension is a problem. Recommend a revisit to be rechecked.
In recording a blood pressure of 120/80 mm Hg, the 120 represents the
A. pulse rate
b. diastolic pressure
c. systolic pressure
d. pulse deficit
C
Systolic is 120, Diastolic is 80. Other responses relate to pulse not blood pressure.
It is important to have the appropriate cuff size when taking blood pressure. A cuff that is too large or too small may result in
a. An incorrect reading
b. Injury to the patient
c. Prolonged pressure on the arm
d. Loss of Korotkoff sounds
A
A patient has intravenous fluids infusing in the right arm. When taking a blood pressure on this patient, the nurse would
a. take the bp in the right arm
b. take the bp in the left arm
c. use the smallest possible cuff
d. report inability to take bp
B
BP should be taken in the arm opposite the one with infusion. The pressure of inflating a cuff on an arm w/ infusion could cause the artery to clot.
temperature
difference between heat produced and heat lost