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Unit 16
Vital/Signs (up dated)
| Question | Answer |
|---|---|
| If you note any abnormality or change in any vital sign, it is your responsibility to | report this immediately to your supervisor. |
| A clinical thermometer should be left in position for | three to five minutes for an oral or rectal temperature. |
| What detects and measures the thermal, infrared energy radiating from blood vessels in the tympanic membrane. | An aural thermometer |
| If a clinical thermometer breaks what could happen? | the mercury can evaporate and create a toxic vapor that can harm both humans and the environment. |
| What must be worn while taking a rectal temperature. | Gloves must be worn |
| A pulse rate below 60 beats per minute is called: | bradycardia |
| Having the forearm rest on the chest makes it easier to: | count respirations after taking a pulse. |
| One respiration | consists of one inspiration and one expiration. |
| Count respirations in such a way that the patient is | unaware of the procedure. |
| Medications such as aspirin or antibiotics are often noted on | a graphic record |
| What should always be used to connect the dots on a graphic record. | A ruler or straightedge |
| What is frequently taken on infants or small children. | An apical pulse |
| What should be bent forward when they are placed in the ears. | The earpieces of the stethoscope |
| What frequently occurs when the heart is weak and not pumping a sufficient amount of blood. | A pulse deficit |
| For the most accurate determination of a pulse deficit, one person should check the apical pulse while | a second person checks the radial pulse. |
| What should be cleaned with alcohol before and after using the stethoscope. | The earpieces and bell or diaphragm of the stethoscope |
| What is indicated when pressures are greater than 140 mm Hg systolic and 90 mm Hg diastolic. | Hypertension |
| What must always be placed on a flat, level surface or mounted on a wall. | A mercury sphygmomanometer |
| Before blood pressure is taken a patient should sit quietly for | at least five minutes |
| Who recommends that two separate blood pressure readings be taken and averaged. | The American Heart Association |
| A sphygmomanometer cuff that is too wide or too narrow | will give inaccurate blood pressure readings |
| Many health care professionals are now regarding the degree of pain as the | fifth vital sign. |
| If hypertension is not treated, it can lead to: | a stroke, kidney disease, and/or heart disease. |
| The measurement of the balance between heat produced and heat lost is ____. | temperature |
| The constant state of fluid balance is __ | homeostasis |
| The most accurate method for taking a temperature is ____. | rectal |
| Which of the following does not lead to increased body temperature? a. illness or infection, b. exercise, c. starvation or fasting, d. excitement | starvation or fasting |
| Before a thermometer is used, it should be soaked in a disinfectant for a minimum of ____. | 30 minutes |
| A pulse site at the neck is the ____. | carotid |
| A pulse is described as regular or irregular by its ____. | rhythm |
| A pulse rate over 100 beats per minute, except in children, is ____. | tachycardia |
| Which of the following is not considered one of the four main vital signs? a. apical pulse, b. pulse, c. temperature, d. respirations | apical pulse |
| Difficult or labored respirations is called ____. | dyspnea |
| Cheyne-Stokes respiration describes periods of ____. | apnea and dyspnea |
| Why are vital signs recorded on a graphic record? | It provides a visual diagram of variations in a person’s vital signs. |
| Heart sounds are caused by ____. | closing of the valves in the heart |
| Constant pressure in the walls of the arteries is called____. | diastolic |
| A factor that does not increase blood pressure is ____. | shock |
| Another term for fever is ____. | pyrexia |
| Difficult breathing with a high-pitched whistling or sighing sound during expiration is ____. | wheezing |
| 97.6 to 99.6°F or 36.5 to 37.5°C | Normal range for oral temperature |
| 98.6 to 100.6°F or 37 to 38.1°C | Normal range for rectal temperature |
| 96.6 to 98.6°F or 36 to 37°F | Normal range for axillary or groin temperature |
| The general range for pulse rates in adults? | 60 to 90 beats per minute |
| Three factors must be noted about the pulse? | rate, rhythm, volume |
| What is the normal rate for respirations in an adult? | 14 to 18 (or 12 to 20) breaths per minute |
| The normal range for diastolic blood pressure? | 60 to 90 mm of mercury |
| What is the normal range for systolic blood pressure? | 100 to 140 mm of mercury |
| Rest or sleep, depressant drugs, shock, excessive loss of blood, fasting | factors that may decrease blood pressure. |
| Stress, anxiety, obesity, high salt intake, aging, kidney disease, thyroid deficiency, arteriosclerosis | possible causes of hypertension. |
| Calculate the pulse pressure if diastolic pressure is 95 and systolic pressure is 140. | 45 |
| Calculate the pulse deficit if the radial pulse is 98 and the apical pulse is 72. | 26 |
| What type of thermometer records the aural temperature in the ear? | A tympanic thermometer |
| A temporal temperature is similar to a rectal temperature because it measures: | the temperature inside the body or bloodstream |
| Prehypertension occurs when | the diastolic reading is between 80 to 89 mm Hg |
| The correct way to measure blood pressure is | the length of the bladder on the cuff should be approximately 80 percent of the circumference of the patient's upper arm |
| A nursing assistant notes a patient's blood pressure to be 148/96. What would be the best action the assistant should take | report the reading to the patient's nurse |
| you were assigned to take vital signs on an 80 year old male nursing home resident who was recently admitted after having a stroke. vital signs were B/P 130/90, T 99.4F, P 92, R 32. Which vital sign reflects a measurement within normal limits? | temperature |
| Which patient is the BEST candidate for an oral temperature? a. 1 year old healthy infant, b. 16 year old receiving his annual physical exam, c. 21 year old patient on seizure precautions, d. 62 year old comatose patient | 16 year old receiving his annual physical exam |
| A patient with tachcardia MOST likely has a/an: a. elevated temperature, b. elevated blood pressure, c. fast pulse, d. increased respiratory rate | c. fast pulse |
| The LEAST accurate route for measuring temperature is: a. aural, b. axillary, c. oral, d. rectal | axillary |
| Which is considered to be an elevated temperature? a. aural 37.2C, b. axillary 38.4 C, c. oral 37C, d. rectal 37.8C | axillary 38.4C |
| Pulse rates are commonly measured at which site? a. apical, b. brachial, c. carotid, d. radial | radial |
| What is the respiratory rate of a patient who is observed to have 16 inspirations and 16 expirations? | 16 |
| In a blood pressure measure measurement of 132/86, the number 86 is the: | systolic |
| Before taking vital signs on a patient, what should you do FIRST? | introduce your self |
| In order to avoid errors, whose approved list of abbreviations should you use when documenting vital signs? | your employer |
| How does the pulse rate and respiratory rate of a healthy toddler compare to that of a health 21 year old? | higher pulse, higher respirations |
| The terms, weak and thready, are MOST usually associated with which vital sign measurement | respirations |
| Which thermometer requires it be "shaken down"? | glass |
| In which procedure is lubricant required? | rectal temperature |
| A febrile patient will exhibit a/an: | elevated temperature |
| When taking a pulse, why should the thumb NOT be used? | the thumb has a pulse and can be confused with the patient's pulse |
| The bladder of a blood pressure cuff needs to cover what percent of the length of the upper arm? | 80% |
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