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mta-chapter 21
measuring vital signs
Question | Answer |
---|---|
body temp is regulated by | air movement,which causes heat to be transferred from the skin to the air molecules by convection |
_____ is necessary for alveoli to remain open | surfactant |
what changes in vitals ocurr in the elderly? | rhythm may be slightly irregular(normal range of heart rate does not change) |
what is a pulse deficit? | the difference between the apical and radial pulses.(apical minus radial) |
a critically ill patient has fast,deep, then slow respirations. these are followed by a period of no breathing for 21 seconds with continuation of this cycle. this resppritory pattern is? | cheyne-stokes respirations |
the correct technique to measure a patients blood pressure (bp) is? | that the brachial artery should be at the level of the right atrium. |
a phase of V Korotkoff sound is? | silence, it makes diastolic pressure in adults |
a nurse finds that a patients vitals have significantly changed. the nurse should : | notify the health care provider, notification and response should be documented |
___ are substances that cause fevers. | pyrogens. pyrogens include bacteria that cause an immune response, which results in a temp raise |
a patient has a high fever that has persisted for 3 days. what should be recognized as being associated with a prolonged fever? | deyhydration,delirium, and convulsions |
apnea | absence of breathing |
bradycardia | pulse rate less than 60 bpm |
crackles | abnormal musical lung sound |
defervescence | abatement of fever |
hypoxia | decreased oxygen in the blood |
arrhythmia | irregular heart rate |
pulse deficit | difference between the radial and apical pulse |
stridor | high pitched cowing sound on inspiration |
tachycardia | pulse rate greater than 100 bpm |
tachypnea | rapid respiratory rate |
bradypnea | slow,shallow breathing |
dyspnea | difficult and labored breathing |
found below the line for bp | diastolic pressure |
an abrupt decline in fever is called a: | crisis |
fever is caused by | rise in metabolism |
the patient who has a fever should be prevented from chills because: | muscle action of shivering raises heat production. |
systolic blood pressure is the pressure: | exerted on the artery during left ventricular contraction. |
if overhydration occurs, the blood pressure will : | increase |
when measuring a pateints bp in the arm, the arm should be positioned: | straight and at the level of the heart. |
when measuring respirations the patient should be: | not be talking or aware your taking the measurement |
when checking pedal pulses, if in doubt about whether the pulse is present,you should | use a doppler stethoscope or device. |
a type of korotkoff's sound that indicates the diastolic pressure in children and in some adults is: | muffling |
when measuring blood pressure with an aneroid manometer, it is important to: | deflate the cuff slowly while observing the dial |
biot's respirations ocurr in patients with increased intracranial pressure and are characterized by: | two or three shallow breaths followed by a period of apnea |
as an infant grows, the heart rate slows. a heart rate within normal limits for a 6-month-old infant is: | 124 bpm |
a normal respitory rate in a 7-year-old child would be ____ than an adult. | higher |
temp greater than 105.8f or 41c should be treated promptly to reduce the fever because of: | potential damage to the cells of the central nervous system |
a person who makes harsh high sounds upon inspiration has what kind of respiratory condition? | stridor |
pulse oximetry is used to: | determine the amount of oxygen carried in the blood. |
a patient who has a bp decrease from supine to standing of 20mm hg or systolic, or 10mm hg or more diastolic, has: | orthostatic hypotension |
a patient whose bp is consistenly 136/80 is classified as having | prehypertension |
symptoms of shock that may be seen with hypotension are: | apprehension, tachycardia, and cool clammy skin |
a patient's whose heart rate is irregular should have their vitals checked: | by taking the apical pulse for the full 60 seconds |
what are the 5 food groups? | grains, vegetavles, fruits, milk, and meat/beans. |
servings per day for grains? | 6 oz |
servings per day for vegetables? | 2 1/2 cups |
servcings per day for fruit? | 2 cups |
servings per day for milk? | 2 cups ages 2-8, 3 cups ages 9-up |
servings per day for meet/beans? | 5 1/2 oz |
Aim to eat less than _____ of cholesterol each day. | 300 mg |
Aim to eat less than _____ of sodium per day. | 2300 mg |
the phase in which th ventricles contract to eject blood | systole |
the measurement of pressure pulsations exerted against the blood vessel walls during systole and distole. | blood pressure |
the measurement of blood that enters the aorta with each ventricular contraction | stroke volume |
the volume of blood pumped in one minute | cardiac output |
the phase in which ventricles are relaxed and no blood is being ejected | diastole |
the measurement of the ratio of stroke volume to compliance of the arterial system | pulse pressure |
when instructing a patient on how to weigh themselves: | they should weigh themselves at the same time everyday wearing the same types of clothing |
5 vital signs? | temperature, pulse, respiration, blood pressure, and pain. |
what gives indicators as to the current health status of the patient and clues to changes in conditions as they occur? | vital signs |
what are 5 times you should obtain vitals? | 1.when admitted, 2.before and after surgery,3.before and after an invasive procedure, 4.before and after certain meds, 5.when the patient's condition changes. |
as _____ increases, heat increases. | metabolism |
when the body is invaded by pathogens: | it elavates the temp to elevate the basal metabolic rate in an effort to destroy pathogens. |
BMR is affected by what hormones? | thyroid, epinephrine, norepinephrine, and testosterone. |
shivering can increase heat production up to ___ times normal. | 5 |
is a fever caused by pathogens. | pyrexia |
thermostat to control body temp? | hypothalamus |
an increase in body temp results in peripheral vasoldilation and ______. | diaphoresis(sweating) |
4 ways to lose heat? | radiation, conduction, convection, and evaporation. |
heat being lost by evaporation results in _____ loss of water each day. | 800ml |
when envirenment conditions produce an elevation in body temp, diaphoresis results. this is an attempt to cool the body by which way? | evaporation |
how do you check pulse deficit? | simultaneosly have on e person count the apical pulse and another person count the radial pulse. |
eupnea | easy respirations of normal rate |
bradypnea | a respiratory rate of 10 or lower. |
tacypnea | a respiratory rate of 24 or above |
hyperventilation | deep rapid respirations |
diaphragmatic breathing | breathing from the abdomen |
dyspnea | labored or forceful breathing, using accessory muscles in the chest and neck |
apnea | absence of breathing |
pulse points | temporal,carotid,apical,brachial,radial,femoral,popliteal,posterior tibial, and dorsalis pedis |
respration | is the exchange of oxygen and carbon dioxide in the lungs and tissue and is initiated by the act of breathing. |
systolic pressure | is the maximum pressure exerted on the artery during left ventricular contraction(systole) |
diastolic pressure | is the lower pressure exerted on the artery when the heart is at rest between contractions(diastole) |
postoperative patient's first temp reading is 100.4, what should be done? | take temp again in 2 hours. |
why should a temp reading greater than 105.8 be treated promptly? | potential damage to the cells of the central nervouse system. |
patient has respitory rate of 16 per minute, what should be done? | note on chart |
person who makes harsh high sounds upon inspiration has what kind of respiratory condition? | stridor |
pulse oximetry is used to: | determine the amount of oxygen carried in the blood. |
a patient who has a blood pressure decrease from supine to standing of 20mmhg or more systolic, or 100mmhg or more diastolic, has _________. | orthostatic hypotension |
a patient whose blood pressure is consistently 136/80 is classified as having: | prehypertension |