Nursing 1111 Ch 14 Vital Signs

Front 1

Measurement in the lower extremities may be ____ to ______ mm Hg higher in the systolic reading than that of the upper extremities.

Back 1

10 to 40

Front 2

What signs or symptoms do you expect to find with a patient who is febrile?

Back 2

• Increased body temperature
• Flushed, dry, warm skin
• Chills
• Feeling of malaise
• Tachycardia

Front 3

What interventions are indicated for a febrile patient?

Back 3

•Assessment of vital signs, especially temperature
•Observation of patient response, including skin color and temperature, and chills
•Promotion of patient comfort, responding to chills, thirst
•Collection of appropriate specimens, such as blood cultures
•Promotion of rest and reduction of activities that increase heat production
•Promotion of heat loss by removing coverings and keeping the patient dry
•Provision of care to meet increased metabolic demands, including oxygen, nutrition, and fluid requirements
•Monitoring of ongoing status

Front 4

(def)
Hypotension

Back 4

Decrease of systolic and diastolic pressure below normal

Front 5

(def)
Febrile

Back 5

Another word for fever

Front 6

(def)
Hyperventilation

Back 6

Rate and depth of respiration increases

Front 7

(def)
Vasodialation

Back 7

Widening of blood vessels

Front 8

(def)
Bradycardia

Back 8

Pulse rate less than 60 beats per minute for an adult

Front 9

(def)
Hypertension

Back 9

140/90 mm Hg for two or more readings

Front 10

(def)
Tachypnea

Back 10

abnormally rapid rate of breathing

Front 11

(def)
Hypothermia

Back 11

Decreased body temperature

Front 12

Apnea

Back 12

No respirations for several seconds

Front 13

(def)
Bradypnea

Back 13

abnormally slow rate of breathing

Front 14

(def)
Eupnea

Back 14

Normal breathing

Front 15

(def)
Auscultatory gap

Back 15

Temporary disappearance of sounds between Korotkoff sounds

Front 16

Give conversion for Fahrenheit to centigrade and
centigrade to Fahrenheit

Back 16

(F-32) X 5/9 = C
(9/5 x C)+ 32 =F

Front 17

The nurse is alerted to temperature alterations of above ______ F or below _____ F on an oral Fahrenheit thermometer, and measurements above ______or below ________on an oral centigrade scale.

Back 17

100.4° F or below 96.8° F
38° C or below 36° C

Front 18

Rectal temperature readings may be _____F or ____ C higher than oral measurements, with axillary readings ranging this same number of degrees lower than oral temperatures.

Back 18

0.9° F or 0.5° C higher

Front 19

Locate pulse points
Carotid
Brachial
Radial
Apical
Dorasalis pedis

Back 19

Front 20

True or False

Vital signs may not be delegated to unlicensed assistive personnel

Back 20

False

Front 21

Interventions that reduce body temperature are:

Back 21

a. Conduction: ice packs, tepid baths
b. Convection: fans

Front 22

The thermometer of choice for a patient in isolation is a ______________________ thermometer.

Back 22

disposable chemical dot

Front 23

A pulse deficit is assessed by two nurses who synchronize their measurement of the patient’s ____and ______ pulses.
A deficit is found if there is a ________between the two readings.

Back 23

apical and radial
difference

Front 24

For a patient who has had a right mastectomy, the _________ or ________ extremities should be used for blood pressure measurement.

Back 24

left arm or lower extremities

Front 25

Vital signs are usually recorded on a ______or _______sheet.

Back 25

graphic or flow sheet.

Front 26

Decreasing hemoglobin levels will __________ the respiratory rate.

Back 26

increase

Front 27

A pulse oximeter may be applied to the ____________, _____________, ______________ .

Back 27

earlobe, finger, or bridge of the nose.

Front 28

The expected SpO2 level is ______________________

Back 28

greater than 90%.

Front 29

The correct techniques for blood pressure measurement include;

Back 29

1. cuff is 40% of the circumference of the limb being used
2. cuff is deflated at a rate of 2 to 3 mm Hg per second
3.cuff is inflated to 30 mm Hg above the point where the pulse disappears.
4. systolic blood pressure is identified as the first onset of Korotkoff sounds

Front 30

The appropriate action is to wait _________ minutes before measuring the temperature if the patient has smoked, chewed gum, or ingested hot or cold liquid or food.

Back 30

15 to 30 minutes

Front 31

A patient’s blood pressure may need to be palpated if the patient's

Back 31

arterial sensations are too weak to create Korotkoff sounds, (e.g. as with severe blood loss)

Front 32

How are the following vital signs measured differently in children?
a. Temperature:
b. Blood pressure

Back 32

a. Temperature: Sites for measurement will vary depending on the child’s age and condition. For example, it is contraindicated to take a tympanic membrane temperature on a child with otitis media.
Tympanic membrane: Used in children age 2 and older
Axilla: Used with newborns and children of any age
Temporal artery: Used in premature infants, newborns, and children
b. Blood pressure: An infant or child younger than 5 years of age lies supine with the arm supported at heart level. Older children sit. It is important for the child to be relaxed and calm. Allow at least 15 minutes for children to recover from recent activity or excitement before taking a reading. It may be helpful to have a parent present. You prepare the child for the BP cuff’s unusual sensation during inflation. The cuff needs to be the appropriate width: infant cuff is 21⁄2 to 31⁄4 inches; child cuff is 4 3⁄4 to 51⁄2 inches.

Front 33

Discuss the correct techniques for a tympanic temperature measurement are a, b, and f.

Back 33

1. Using the right ear if the pt has been lying down on his/her left side in bed
2. Pointing the probe midpoint between the eyebrows and sideburns for children younger than 3 years of age
3. Waiting 2 to 3 minutes before repeating the measurement in the same ear

Front 34

A patients pulse is expected to be increased in the presence of which following factors

Back 34

1. Anxiety
2. Presence of asthma
3. Hemorrhage

Front 35

Adult vital signs
Pulse=
Blood pressure normal=
pre hypertension=
hypertension=
Respiration =

Back 35

Pulse 60 to 100 beats per minute
Blood pressure normal 120/80
pre hypertension= 120- 139 (systolic) 80- 89 (diastolic)
hypertension=140- 159 (systolic) 90- 99 (diastolic)
Respirations 12 to 20 breaths per minute

Front 36

Child vital signs (age 1 to 8 years)
Pulse =
Blood pressure =
Respirations =

Back 36

Pulse 80 to 100 beats per minute
Blood pressure 105/65 mmHg
Respirations 20 to 30 breaths per minute

Front 37

Infant vital signs
Pulse
Blood pressure
Respirations

Back 37

Pulse 120 to 160 beats per minute
Blood pressure 85/54 mm Hg
Respirations 30 to 50 breaths per minute

Front 38

A patients body temperature may be reduced after ?
1. Exercise
2. Emotional stress
3. Periods of sleep
4. Cigarette smoking

Back 38

3. Periods of sleep

Front 39

A decrease in the pt's pulse rate is a result of
1. Hemorrhage
2. Hyperthyroidism
3. Respiratory difficulty
4. Epinephrine administration

Back 39

2. Hyperthyroidism

Front 40

A patient is being treated for Hyperthermia what is the patients response to this condition?
1.Generalized pallor
2. Bradycardia
3. Reduced thirst
4. Diaphoresis

Back 40

4. Diaphoresis
( profuse sweating)

Front 41

What would you give a patient that is slightly Hypothermic
1. Soup
2. Coffee
3. Cocoa
4. Brandy

Back 41

1. Soup

Front 42

A patient that is febrile - what type of antipyretic medication is ordered
1. Digoxin
2. Prednisone
3. Theophylline
4. Acetaminophen

Back 42

4. Acetaminophen

Front 43

When taking VS, the nurse is alert to the greater possibility of tachycardia for the patient with:
1. Anemia
2, Hypothyroidism
3, a temp of 95° F
4. A pt-controlled analgesic pump (PCA) w/ morphine drip

Back 43

1. Anemia

Front 44

With a hypotensive patient the nurse should be checking to see if the pt is experiencing:
1. Lightheartedness
2. A decreased heart rate
3. An increased urinary output
4. increased warmth to the skin

Back 44

3. An increased urinary output

Front 45

Vital signs that need immediate report of findings are:
1. Pulse pressure of 40 mm Hg
2. Apical pulse of 78,80,76 beats per min
3. Apical pulse of 82 beats per min; radial pulse of 70 beats per min
4. BP of 140/80 LA , 136/74 RA

Back 45

3. Apical pulse of 82 beats per min; radial pulse of 70 beats per min

Front 46

Pulse Adult
Normal range =
Tachycardia =
Bradycardia =

Back 46

normal = 60-100
>100 = tachycardia
<60 = bradycardia

Front 47

A tympanic temp assessment is indicated for which pt:
1. After rectal surgery
2. wearing a hearing aid
3. Experiencing otitis media
4. After an exercise session

Back 47

1. After rectal surgery

Front 48

Otitis media

Back 48

An ear infection, most often bacterial or viral infection affects the middle ear

Front 49

Taking BP on a cardiac care unit- what type of patient should you use a automatic BP device on
1. An irregular heart beat
2. Parkinson disease
3. Peripheral vascular disease
4. A systolic BP great than 104 mmHg

Back 49

4. A systolic BP great than 104 mmHg

Front 50

34 yr old pt annual physical exam- the nurse alerts the Dr to vital findings of:
1. T: 37.6 C
2. P: 120 bpm
3. R: 18 bpm
4. BP: 116/78 mmHg

Back 50

2. P: 120 bpm

Front 51

Where would you check the pulse rate of a child 1 1/2 yr old:
1. Radial artery
2. Apical artery
3. Politeal artery
4. Femoral artery

Back 51

2. Apical artery

Front 52

Pt pulse rate is significantly lower that it has been during the past week. The nurse reassesses and finds that the pulse rate is 46 bpm. The nurse should first:1. 1. Document the measurement
2. Administer a stimulant medication
3. Inform the charge nurse or physician
4. Apply 100% O2 at max flow rate

Back 52

3. Inform the charge nurse or physician

Front 53

The most important sign of heat stroke is:
1. Hot, dry skin
2. Nausea
3. Excessive thirst
4. Muscle cramping

Back 53

1. Hot, dry skin

Front 54

The most accurate temp measurement fro an adult pt experiencing tachypenea and dyspnea is:
1. Oral
2. Rectal
3. Axillary
4. Tymphanic

Back 54

4. Tymphanic

Front 55

what is the correct number of inches for insertion of a rectal thermometer
adult=
child=
infant=

Back 55

adult= 1 to 1 1 1/2
child= 1/2 to 1
infant= 1/2

Front 56

Intermittent fever is observed by:
1. A constant body temp greater than 38° C (100.4°F)
2. A fever that spikes and falls but does not return to normal
3. Long periods of normal temps with febrile episodes
4. Spikes in readings mixed with normal temps.

Back 56

4. Spikes in readings mixed with normal temps.

Front 57

What is the correct pulse pressure for a pt with a blood pressure of 170/90?

Back 57

80

Front 58

For a pt that is experiencing a febrile state the nurse should:
1. Ambulate the pt
2. Restrict fluid intake
3. Keep the patient warm
4. Provide oxygen as ordered

Back 58

4. Provide oxygen as ordered

Front 59

A nurse anticipates that bradycardia will be evident if a patient is:
1. Exercising
2. Hypothermic
3. Asthmatic
4. Extremely anxious

Back 59

2. Hypothermic

Front 60

A nurse anticipates that a pt with hypertension will be receiving:
1. Diuretics
2. Antipyretics
3. Narcotic analgesics
4. Anticholinergics

Back 60

1. Diuretics

Front 61

To determine arterial blood flow to a pt feet the nurse should assess which artery?

Back 61

Dorsalis pedis artery

Front 62

A nurse anticipates an increase in BP for the pt who is:
1. Sleeping
2. Overweight
3. Taking narcotics
4. Hemorrhaging

Back 62

2. Overweight

Front 63

(def)
Body temperature

Back 63

•Heat produced minus heat loss = body temp

Front 64

(def)
Radiation

Back 64

Transfer of heat between objects without physical contact

Front 65

(def)
Conduction:

Back 65

Transfer heat from one object to another with direct contact

Front 66

(def)
Convection:

Back 66

Transfer of heat away by air movement

Front 67

(def)
Evaporation:

Back 67

Transfer of heat energy when liquid is exchanged to a gas

Front 68

give two other words for Fever

Back 68

pyrexia and ‘febrile’

Front 69

Hypothermia=
Environmental =
Intentional =

Back 69

temp below normal
winter, frost bite- cold water drowning
surgery - cool (metabolic rate) brains and tissues don't need O2

Front 70

Hyperthermia=
Environmental =
Malignant =

Back 70

temp above normal
dehydration
trauma, medication

Front 71

Advantages of assesing Temps
Fast =
Easy access =
Responds quickly to changing core temp =
Most accurate (not subject to user error or environmental factors) =

Back 71

Fast - tympanic, temporal
Easy access – oral, tympanic, temporal
Responds quickly to changing core temp – oral, tympanic, temporal
Most accurate (not subject to user error or environmental factors) – rectal

Front 72

Rectal temp is ______ degree C > than oral (highest)
Oral temp is ______ degree C > than axillary (lowest)

Back 72

0.5 degree C > than oral (highest)
0.5 degree C > than axillary (lowest)

Front 73

S1 (lub) + S2 (dub) = ______ beat

Back 73

1

Front 74

(def)
Pulse deficit

Back 74

difference between apical and peripheral count

Front 75

Pulse rate ___________________ with age

Back 75

decreases

Front 76

Blood pressure starts lower in __________________as we age.

Back 76

increases

Front 77

How do you measure to make sure BP cuff is correct for patient

Back 77

Cuff width (40-60% arm circumference)
Bladder length (80-100% arm circumference)

Front 78

How much do you Inflate the cuff above usual systolic pressure.

Back 78

quickly to 30 mm Hg

Front 79

What happens - to a
Cuff that is too small
Cuff too loose
Arm held below heart
Arm not supported

Back 79

False high:
Heart overpowers cuff. Sounds are heard early

Front 80

What happens - to a
Cuff that is too big
Arm held above the heart

Back 80

False low:
Cuff overpowers heart. Sounds are heard late

Front 81

Inhalation + exhalation =

Back 81

1 respiration

Front 82

Normal respiration

Back 82

12 to 20 breaths per minute in a smooth, uninterrupted pattern

Front 83

(def)
eupnea

Back 83

Normal rate and depth -

Front 84

(def)
tachypnea

Back 84

Rapid respiration

Front 85

(def)
bradypnea

Back 85

Slow respiration

Front 86

(def)
dyspnea

Back 86

Labored respiration

Front 87

Respiration and pulse go ________as the person gets older

Back 87

down

Front 88

Blood pressure goes _______ as the person gets older

Back 88

up

Front 89

Temperature _________ as the person gets older

Back 89

stays the same

Front 90

(def)
Systolic

Back 90

Peak pressure when heart is contracting

Front 91

(def)
Diastolic

Back 91

Relaxation, lowest pressure exerted

Front 92

(def)
Pulse pressure

Back 92

Difference between systolic and diastolic pressures