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Chapter 26

Measuring Vital Signs

QuestionAnswer
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