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Chapter 27
Measuring Vital Signs
| Question | Answer |
|---|---|
| The four _________ __________ of body function are: temperature, pulse, respiration, and blood pressure. | Vital signs |
| The persons vital signs ____________ and are affected by sleep, activity, eating, weather, noise, exercise, medications, anger, fear, anxiety, pain, and illness. | Vary |
| Vital signs are measured to detect _________ in normal body function. | Changes |
| Vital signs tell about _____________ responses. | Treatment |
| Vital signs often signal ________-__________ events. | Life-threatening |
| Vital signs are measured: during the physical ___________. | Exam |
| Vital signs are measured: when the person is _______________ to the center. | Admitted |
| Vital signs are measured: as often as the person's ______________ requires. | Condition |
| Vital signs are measured: before and after _____________, complex procedures, and diagnostic tests. | Surgery |
| Vital signs are measured: after some care measures, such as ________________. | Ambulation |
| Vital signs are measured: after a ____________ or other injury. | Fall |
| Vital signs are measured: when _______________ affect the respiratory or circulatory system. | Medications |
| Vital signs are measured: when a person complains of __________, dizziness, light-headedness, feeling faint, shortness of breath, a rapid heart rate, or not feeling well. | Pain |
| In most cases you should take vital signs when the person is at rest - __________ down or sitting. | Lying |
| Report any vital sign at once that is _________________ from a prior measurement. | Changed |
| Report any vital sign at once that is above the _____________ range. | Normal |
| Report any vital sign at once that is _________________ the normal range. | Below |
| What is the amount of heat in the body called? | Body temperature |
| Body temperature is the balance between the amount of heat _______________ and the amount lost by the body. | Produced |
| Body temperature is lowest in the _________________. | Morning |
| Pregnancy and a woman's _______________ cycle affect body temperature. | Menstrual |
| Temperature _____________ are the mouth, rectum, axilla, tympanic membrane, and temporal artery. | Site |
| Axillary temperature is measured in the ___________. | Armpit |
| Tympanic membrane temperature is measured in the ___________. | Ear |
| A temporal artery temperature is measured on the _____________. | Forehead |
| What type of thermometers have been eliminated from the healthcare setting due to hazards of mercury exposure and risk of injury from broken glass? | Glass thermometers |
| Rectal temperatures require a special thermometer or a special rectal probed which is color-coded ____________. | Red |
| Which temperature site is not used if the person is unconscious? | Oral |
| Which temperature site is not used if the person is receiving oxygen therapy? | Oral |
| Which temperature site is not used if the person has heart disease? | Rectal |
| Which temperature site is not used if the person has a naso-gastric tube? | Oral |
| Which temperature site is not used if the person has an ear infection? | Tympanic membrane |
| Which temperature site is non-invasive? | Temporal artery |
| Which temperature site is not used if the person is paralyzed on one side of the body? | Oral |
| Which temperature site is not used if the person has a convulsive (seizure) disorder? | Oral |
| Which temperature site is the least reliable? | Axillary |
| A baseline temperature of 98.6 F is for the ___________, tympanic membrane, temporal artery sites. | Oral |
| A baseline temperature of 99.6 F is for the ____________ site. | Rectal |
| A baseline temperature of 97.6 is for the ____________ site. | Axillary |
| The normal range for body temperature is one _____________ above and below the baseline measurement. | Degree |
| The _____________ ____________ temperature is measured in 1-3 seconds. | Tympanic membrane |
| Before taking a temperature you need the following information from the nurse and the care plan: what _____________ to use. | Site |
| Before taking a temperature you need the following information from the nurse and the care plan: what __________________ to use for each person. | Thermometer |
| Before taking a temperature you need the following information from the nurse and the care plan: ____________ to take temperatures. | When |
| Before taking a temperature you need the following information from the nurse and the care plan: which persons are at risk for ______________ temperatures. | Elevated |
| Which non-invasive site measures body temperature in 3-4 seconds? | Temporal artery |
| The rectal temperature is taken with the person in _____________ position. | Sim's |
| Tympanic membrane and temporal artery thermometers are used for persons who are ____________ and resist care. | Confused |
| When taking an ____________ temperature you need to ask the person not to eat, drink, smoke, or chew gum for at least 15-20 minutes before the procedure. | Oral |
| For a _____________ temperature you must lubricate the end of the covered probe. | Rectal |
| When taking an axillary temperature, you must first _____________ the axilla. | Dry |
| Temperature sensitive tape is applied to the _________________. | Forehead |
| What is the beat of the heart felt at an artery as a wave of blood passes through the artery? | Pulse |
| Which pulse site is used most often? | Radial |
| What is the name of the pulse heard over the heart? | Apical |
| What instrument do you use to measure the apical pulse? | Stethoscope |
| What is an instrument used to listen to the sounds produced by the heart, lungs, and other body organs? | Stethoscope |
| Before using a stethoscope you need to wipe the ______-__________ and diaphragm with antiseptic wipes. | Ear-pieces |
| Normal pulse ___________ for an adult is 60-100 beats per minute. | Rate |
| What is the number of heartbeats or pulses felt in 1 minute? | Pulse rate |
| When using a stethoscope, you need to ____________ the diaphragm in your hand before applying it to the person's skin. | Warm |
| What is a rapid heart rate, more than 100 beats per minute? | Tachycardia |
| What is a slow heart rate, less than 60 beats per minute? | Bradycardia |
| The pulse _____________ should be regular, the pulses are felt in a pattern. | Rhythm |
| An _________________ pulse occurs when the beats are not evenly spaced or beats are skipped. | Irregular |
| ___________ relates to pulse strength. | Force |
| A forceful pulse is ____________ to feel. | Easy |
| A forceful pulse is described as ___________, full, or bounding. | Strong |
| Hard-to-feel pulses are described as weak, _________, or feeble. | Thready |
| Electric blood _______________ equipment can also count pulses. | Pressure |
| When using an electric blood pressure device the pulse _________ is shown. | Rate |
| Some electric blood pressure devices show the pulse ____________. | Rhythm |
| When using an electric blood pressure device, you still need to manually feel the pulse to determine its ______________. | Force |
| When taking a ______________ pulse, you place your first two fingertips on the thumb side of the wrist. | Radial |
| When taking a radial pulse, you count the pulse for 30 seconds and then multiply that number by __________. | 2 |
| An ____________ pulse is taken by using a stethoscope. | Apical |
| You count the apical pulse for _______ minute. | 1 |
| When taking an apical pulse you will hear a lub-dub sound. Each lub-dub is _________ pulse beat. | 1 |
| The apical and radial pulse rates should be _____________. | Equal |
| How many staff members are needed to take an apical-radial pulse? | Two |
| What is it called when you take the apical and radial pulses together? | Apical-radial pulse |
| What is the difference between the apical and radial pulse rates? | Pulse deficit |
| To calculate the pulse deficit you _____________ the radial pulse from the apical rate. | Subtract |
| The radial pulse will never be ______________ than the apical rate. | Greater |
| When taking an apical-radial pulse, you count the pulse for ______ minute. | 1 |
| What term means breathing air into (inhalation) and out of (exhalation) the lungs? | Respiration |
| A healthy adult has _______ to 20 respirations per minute. | 12 |
| Count each rise and fall of the chest a ________ respiration. | 1 |
| Begin counting respirations when the chest ____________. | Rises |
| Count respirations right ____________ taking the pulse. | After |
| When counting respirations you need to keep your fingers or stethoscope over the ____________ site. | Pulse |
| Count the respirations for _________ seconds and then multiply that number by 2. | 30 |
| When counting respirations you should note: if the respirations are ______________. | Regular |
| When counting respirations you should note: if both sides of the chest rise ______________. | Equally |
| When counting respirations you should note: the ___________ of the respirations. | Depth |
| When counting respirations you should note: if the person has any pain or difficulty __________________. | Breathing |
| When counting respirations you should note: if the person has an abnormal respiratory _____________. | Pattern |
| What is the amount of force exerted against the walls of an artery by the blood? | Blood pressure |
| What is the period of heart muscle contraction (when the heart is pumping blood) called? | Systole |
| What is the period of heart muscle relaxation (when heart is a rest) called? | Diastole |
| What is the pressure in the arteries when the heart contracts? | Systolic pressure |
| What is the pressure in the arteries when the heart is at rest? | Diastolic pressure |
| Blood pressure is measured in millimeters (mm) of __________ (Hg). | Mercury |
| The normal range for systolic pressure is less than ___________ mm Hg. | 120 |
| The normal range for diastolic pressure is less than _________ mm Hg. | 80 |
| Blood pressure measurements remaining above 140 mm Hg systolic, or a diastolic pressure above 90 mm Hg is called _______________. | Hypertension |
| Blood pressure measurements below 90 mm Hg systolic, or a diastolic pressure below 60 mm Hg is called _______________. | Hypotension |
| You use a __________________ and a sphygmomanometer to measure blood pressure. | Stethoscope |
| The sphygmomanometer has a __________ and a measuring device. | Cuff |
| Factors affecting blood pressure include: Age - blood pressure _____________ with age. | Increases |
| Factors affecting blood pressure include: Gender - women usually have ____________ blood pressure than men do. | Lower |
| Factors affecting blood pressure include: Blood volume - severe bleeding _____________ blood volume, therefore BP decreases. | Lowers |
| Factors affecting blood pressure include: Stress - BP ______________ as the body responds to stress (anxiety, fear, and emotions) | Increases |
| Factors affecting blood pressure include: Pain - pain generally __________ BP. | Increases |
| Factors affecting blood pressure include: Exercise - BP ____________. | Increases |
| Factors affecting blood pressure include: Weight - BP is _____________ in over-weight persons. | Higher |
| Factors affecting blood pressure include: Race - African-Americans generally have _____________ BPs than whites. | Higher |
| Factors affecting blood pressure include: Diet - A high-sodium diet increases the amount of water in the body causing increased fluid volume which ______________ BP. | Increases |
| Factors affecting blood pressure include: Medications - can be given to _____________ or lower BP. | Raise |
| Factors affecting blood pressure include: Positioning - BP is ____________ when lying down. | Higher |
| Factors affecting blood pressure include: Positioning - Sudden changes in positions can cause a sudden ____________ in BP. | Drop |
| A sudden drop in BP is called orthostatic _______________. | Hypotension |
| Factors affecting blood pressure include: Smoking - can __________ BP. | Increase |
| Factors affecting blood pressure include: Alcohol - excessive alcohol intake can ____________ BP. | Raise |
| You measure BP in the __________ artery. | Brachial |
| Guidelines for measuring BP include: Do not take BP on an __________ with an IV infusion, a cast or a dialysis access site. | Arm |
| Guidelines for measuring BP include: Do not take BP on the side that a woman has had ______________ surgery. | Breast |
| Guidelines for measuring BP include: Do not take BP on an ____________ arm. | Injured |
| Guidelines for measuring BP include: Let the person __________ for 10-20 minutes before measuring BP. | Rest |
| If orthostatic vital signs are ordered you should first measure BP and pulse after the person has been ______________ for at least 5 minutes. | Supine |
| If orthostatic vital signs are ordered and you have taken the first set of vitals you then measure pulse and BP while the person ____ at the bedside. | Sits |
| If orthostatic vital signs are ordered the last measurement of BP and pulse that you take is while the person is _____________. | Standing |
| Guidelines for measuring BP include: Putting the cuff on a _____________ arm. | Bare |
| Guidelines for measuring BP include: Using a large cuff if the person is ______________ or has a large arm. | Obese |
| Guidelines for measuring BP include: Placing the diaphragm of the stethoscope firmly over the _____________ artery. | Brachial |
| Guidelines for measuring BP include: Making sure the room is ______________. | Quiet |
| When measuring BP, the first sound you hear is the _______________ pressure. | Systolic |
| When measuring BP, the last sound you hear (when the sound disappears) is the _______________ pressure. | Diastolic |
| If you are not sure the measurement is accurate, wait 30-60 _____________ and repeat the measurement. | Seconds |
| If you are unsure of the measure or you can't _____________ the BP, tell the nurse at once. | Hear |
| When measuring BP do not place the diaphragm _____________ the cuff. | Under |
| Deflate the cuff at an even rate of 2-4 millimeters per ______________. | Second |
Created by:
na3
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