Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Vital Signs
Chapter 12 for Fundamentals
| Question | Answer |
|---|---|
| List the Vital Signs | 1. Temperature 2. Pulse Rate 3. Respiration Rate 4. Blood Pressure 5. Pain |
| 2 Types of Body Temperature | Core and surface |
| Above normal body temperature | Pyrexia, febrile and hyperthermia |
| What part of the body regulates temperature? | Hypothalamus |
| Factors that affects body temperature. | Age, exercise, hormonal influences, diurnal (daily) variations, stress, environment, ingestion of food and hot and cold liquids, smoking. |
| Sign and symptoms of elevated Body temperature | Anorexia, disorientation/convulsions in infants & children, elevated pulse & respiratory rates, flushed warm skin, glassy eyes/photophobia (light sensitivity), headaches, increased perspiration, irritability, restlessness/excessive sleepiness, thirst |
| How much is one kilogram (kg) converted to pounds(lbs)? | 2.2 pounds (lbs) |
| What is the formula for kilogram (kg) to pounds (lbs)? | kg x 2.2 lbs = lbs |
| When should you measure vital signs? | -On admission and discharge to a health care facility. -When assessing a patient during home care visits. -In a hospital on a routine schedule according to orders. |
| Hypothermia? | When the body temperature is abnormally low. |
| Above 100.4 F? | Considered as a fever |
| At what temperature can potentially cause damage to normal body cells ? | 105 F |
| Factor that influence pulse rate. | Acute pain and anxiety (sympathetic stimulation), Age (decreases when getting older), Exercise (short term increases, long term lower hr), Fever & heat (hypothermia decreases HR), Hemorrhage (loos of blood increases HR), Medication |
| Factor that influence pulse rate. | Metabolism (hyperthyroidism elevates while hypothyroidism slows down), Postural changes (lying down decreases), Pulmonary conditions (increase HR), unrelieved severe pain & chronic pain (decreases because of parasympathetic stimulation), |
| Factor that influence pulse rate. | Dehydration (increases) Fluid Volume Excess (Increase HR) |
| Tachycardia | Pulse is faster than 100 beats |
| Bradycardia | Pulse is slower than 60 beats |
| Heart block | cardiac condition that decreases HR |
| Dysrhythmia | irregular pulse |
| Least accurate method of taking tempurature | Axilla |
| Most accurate and reliable temperature | Rectal |
| How long does it take for the body to regulate temperature? | At least 10 minutes |
| What is the normal pulse rate for an adult? | 60-100 HR |
| Diaphragm of stethoscope | Circular flat-surfaced portion of the chest piece that auscultate bowel, lung, and heart sounds, also makes a tight seal against patient's skin |
| Bell of stethoscope | Bowl-shaped chest piece that transmits low-pitched sounds created by low-velocity movement of blood. |
| What can cause postural/orthostatic? | Diuretics/General Anesthesia/Hemorrhage |
| What equipment is needed to take an apical pulse? | stethoscope |
| Explain the difference between systolic and diastolic | systolic - when heart contracts diastolic - when heart relaxes |
| Apical heart rate | number of ventrivular contractions per minute |
| Arrhythmia | irregular patterns of heart beats |
| Bradypnea | slow respiratory rate |
| What part of the body maintains a balance between heat production and heat loss, regulating body temperature? | Hypothalamus |
| What type of body temperature remains relatively constant? | Core |
| The nurse uses cooling techniques to keep the body temperature below 105 F. what can result from an elevated temperature? | Damage to body cells |
| The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. what temperature is the nurse aware of that can lead to death? | 93.2 F |
| What is the term for a fever that rises and falls but does not return to normal until the patient is well? | Remittent |
| How should the nurse position the ear pinna when using the tympanic thermometer on a child? | Downwards and back |
| How should the nurse position the earpieces on a stethoscope to ensure optimum reception? | Towards the face |
| What does the nurse use the diaphragm of the stethoscope to best assess? | Lung sounds |
| What is the pulse - the expansion and contraction of an artery - produced by? | Contraction of the left ventricle |
| When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120 beats/min. what is this pulse interpreted as by the nurse? | Tachycardia |
| The patient's pulse is below 60 beats/min. the nurse is aware that the patients is not receiving digoxin. what does the nurse suspect is causing the bradycardia? | Unrelieved severed pain |
| What site should be selected if a peripheral pulse needs to be assessed quickly? | Carotid pulse |
| What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level? | External respiration |
| A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these 2 rates? | Pulse deficit |
| The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths/min. Where might this finding indicate that there is an injury? | Medulla Oblongata |
| The nurse assesses respiration of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations? | Dyspnea |
| A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 96 F? | Record the findings |
| A nurse assesses a patient's dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding? | Thready pulse |
| A nurse assesses a patient's dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding? | Weak pulse |
| A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding? | Normal pulse |
| A nurse assesses a patient's dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. how should the nurse document this finding? | Bounding pulse |
| When instructing a primary caregiver about keeping a daily log of blood pressure readings, what instructions should the nurse include? | Apply the cuff approximately 2 in above the antecubital fossa Apply the cuff snugly |
| When assessing factors that may influence the patient's pulse rate, what should the nurse take into consideration? | Age Sex Emotion Temperature |
| A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will assessed? | Judgment of need by the nurse Orders of the health care provider Patient's condition |
| The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure? | Proper measurement techniques are necessary Cuff fits over clothing Stethoscope is not required |
| The health care provider orders daily weights on a patient residing in a long-term care setting. what action should the nurse implement to assess weight accurately? | Weigh patient at the same time each day Encourage patient to void before being weighed Ensure same amount of clothing is worm by patient |
| The nurse assesses for the fifth vital sign, which is | Pain |
| If a patient has an axillary temperature of 96.2 F, the nurse understands that the true temperature is | 97.2 F |
| The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse pressure of | 106 |
Created by:
user-1806100
Popular Nursing sets