Chapter 29 - Vital Signs 2

Front 1

If the nurse wanted to check for rapidly changing core temperature, which method would he/she use?

Back 1

Oral or temporal.

Front 2

If the nurse wanted to check a patient's body temperature, but they had just eaten, what alternate method(s) could easily be used?

Back 2

Temporal, axilla, or tympanic.

Front 3

If a patient has recently had a hot cup of tea, and easily gets chilled, what method would be best to take the temperature?

Back 3

Tympanic or temporal.

Front 4

A patient is sweating profusely, is chilled, and is wearing hearing aids, what would be the method of temperature checking?

Back 4

Rectal

Front 5

What are the responsibilities of the nurse when taking temperatures?

Back 5

Choose the best site for measuring for each individual. Always record which site you used. Continue to use the same site to compare to the baseline.

Front 6

Describe the physical characteristics of hyperthermia and give possible diagnoses.

Back 6

Increased body temperature, flushed skin, skin warm to the touch, and tachycardia. Possible diagnoses: Risk for imbalanced body temperature, hyperthermia, or ineffective thermoregulation.

Front 7

A patient is admitted with tachycardia, hypoxemia, warm and dry skin. They are restless and confused, with a flushed appearance. Their temperature is elevated. You find out they were found wandering outside in the 100+ degree weather. What is your diagnosis?

Back 7

Ineffective Thermoregulation Related to Aging and Inability to Adapt to Environmental Temperature.

Front 8

What factors should the nurse consider when promoting balance between heat production and heat loss?

Back 8

Patient activity, temperature of the environment, and clothing.

Front 9

What factors should the nurse consider when planning treatment for fever?

Back 9

The cause of the fever, any adverse effects, and the strength, intensity, and duration of the temp elevation.

Front 10

A child presents with a fever, because of the risk of dehydration and febrile seizures, what steps should the nurse take to monitor the patient?

Back 10

Maintain accurate intake and output records, weigh the patient daily, and encourage fluids.

Front 11

What nursing interventions should be implemented for patients with a fever?

Back 11

Blood cultures that coincide with temperature spikes; reduce ambulation; allow rest periods; reduce external covering without causing shivering; keep clothes/linens dry; provide oxygen as needed; stimulate appetite; provide fluids; promote comfort; identify onset and duration of febrile episodes, watch for trends; initiate health teaching; control environmental temp to 21 to 27 C (70 to 80F)

Front 12

A patient presents with fever, rash, and pruritus. They have recently started a new drug. What is a possible nursing diagnosis? What can be done to treat it?

Back 12

Hypersensitivity response to a drug. Treatment: discontinue use of drug.

Front 13

How do Antipyretics reduce fever? What are some examples of antipyretics?

Back 13

Antipyretics increase heat loss. Acetaminophen, salicylates, indomethacin, and ketorolac

Front 14

Describe the process of blood flow as relating to the palpable pulse.

Back 14

Electrical impulses begin in the Sinoatrial (SA) node and travel through the muscle of the heart. This causes contraction, and 60 to 70 mL of blood enters the aorta (stroke volume). With each stroke volume that is ejected, the walls of the aorta stretch, creating a pulse wave that travels toward the distal ends of the arteries. When the pulse wave reaches a peripheral artery, you can feel it. The number of pulsing senstations occuring in 1 minute is the pulse rate. The volume of blood pumped by the heart during 1 minute is the cardiac output. An adult normally pumps 5000mL of blood per minute through the heart.

Front 15

If the HR increased, what are the possible ramifications for the blood pressure?

Back 15

There would be less time for the heart to fill. So if there is no corresponding change in stroke volume, the BP would decrease. The inability of BP to respond to increases or decreases in HR indicates a possible health problem.

Front 16

If the HR is decreased, what are the possible ramifications for the BP?

Back 16

There would be more filling time, and the BP would increase. The inability of BP to respond to increases or decreases in HR indicates a possible health problem.

Front 17

A patient complains of fatigue. You find that he has an abnormal HR and exertional dyspnea. What would your diagnosis be? What interventions would you institute.

Back 17

Activity intolerance. Interventions would include increasing the patient's daily exercise routine.

Front 18

A patient has chronic lung disease. Do you place this patient on oxygen?

Back 18

No, this would be fatal for a patient with chronic lung disease. The lower levels of arterial O2 provide the stimulus needed to allow the patient to breathe.

Front 19

You want to evaluate tidal volume on a patient. What is considered normal?

Back 19

500mL of air

Front 20

A patient has been in a car accident and has a head injury. You notice a drop in respirations, what could this signify?

Back 20

A brainstem injury.

Front 21

A patient has a long expiration phase. what is a possible explanation?

Back 21

Asthma

Front 22

Acute pain can do what to respiration?

Back 22

Can cause breathing to become shallow, particularly if the injury is in the chest or abdomen.

Front 23

What are three causes of increased respiratory rate related to hemoglobin function?

Back 23

Decreased hemoglobin levels reduces oxygen-carrying capacity of the blood, which increases respiratory rate. Increased altitude lowers amount of saturated hemoglobin, which increases respiratory rate and depth. Abnormal blood cell function (e.g. sickle cell disease) reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth.

Front 24

A patient presents with tachycardia, changes in depth of respirations, use of accessory muscles when breathing, dyspnea, and a decline in SpO2. What is the nursing diagnosis?

Back 24

Impaired gas exchange.

Front 25

a patient presents with hypotension, dizziness, pulse deficit, and dysrhythmia. What is the nursing diagnosis?

Back 25

Decreased cardiac output.