Fundamentals of Nursing Test 3
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
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| 4 Vital signs | 1 Body Temperature 2 Pulse 3 Respirations 4 Blood Pressure
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| Body Temperature 2 definitios | 1 Heat of Body in degrees 2 Difference between heat production and loss
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| Core temperature v Surface | Core temperature is higher
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| Where is the thermoregulatory center? | Hypothalamus
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| The primary source of heat production in the body | Metabolism- the sum of the chemical reactions of the body
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| The primary source of heat loss in the body? | The skin
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| Celcius to Fehrenheit conversion | C = 5/9 (F - 32) or F = 9/5 C + 32
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| d Pulse | A wave of blood from pumping of the left ventricle
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| 3 characteristics of Pulse | 1 Rate 2 Quality of Amplitude 3 Rhythm
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| How is the pulse Rate measured? | bpm Beats per minute
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| How is the quality or amplitude of a pulse measured? 5 | 0 Absent 1+ Thready 2+ Weak 3+ Normal 4+ Bounding
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| How is the Rhythm measured? 4 | Regular Weak Bounding Irregular
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| The pulse is regulated by ( ) through ( ) | The autonomic nervous system through the cardiac sinoatrial node
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| Parasympathetic stimulation | Decreases the heart rate
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| Sympathetic Stimulation | Increases the heart rate
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| d pulmonary ventilation | Moving air in and out of the lungs
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| inspiration | breathing in
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| expiration | breathing out
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| External respiration | Exchange of Oxygen and carbon dioxide between the alveoli and circulating blood
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| Internal respiration | Exchange of oxygen and carbon dioxide between the circulating blood and the tissues
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| Respiratory centers in the (2) do what (2) | medulla and pons inhibit or stimulate respiratory muscles
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| The most powerful stimulant to breathe is ( ) | Carbon Dioxide
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| Can breathing be controlled voluntarily? If so how? | Yes, through the cerebral cortex
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| d. Blood Pressure | Force of blood through arterial walls
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| How is blood pressure recorded? | Measured as mm of Mercury (HG)
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| Systolic pressure | The highest pressure- left ventricle contracts
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| Diastolic pressure | The lowest pressure- heart rests between beats
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| Pulse pressure | Systolic minus Diastolic
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| Korotkoff Sounds | A series of sounds a nurse listens for when assessing blood pressure
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| KS Phase 1 | The first faint tapping sounds; the systolic pressure
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| KS Phase 2 | Swooshing sound called the ausculatory gap
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| KS Phase 3 | Distinct loud sounds
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| KS phase 4 | distinct abrupt muffling sound; first diastolic figure
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| KS phase 5 | Last sound heart; second diastolic measurement
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| 3 constant minor variations in blood pressure | 1 Peripheral Resistance 2 Neural and Humoral mechanisms 3 Cardic Output
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| Peripheral Resisance and BP | Contraction and Relaxation of Arterioles alters the BP
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| Neural and Humoral mechanisms and BP | Kidneys and Posterior Pituitary alter BP
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| Cardiac Output and BP | The amount of blood pumped per min varies and alters BP
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| Circadian Rhythm | Predictable repeated 24 hour fluctuations in physiologic processes
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| Time of day when temp is highest and lowest | Lowest in early morning, highest in late afternoon
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| 2 age groups most sensitive to environmental changes to body temperature | Old and young
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| Which gender has more body temp fluctuations? | Women
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| Hyperthermia | High body temperature
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| Hypothermia | Low body temperature
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| Pyrexia | Increased body temperature caused by upward tick in hypothalamic center set point
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| Febrile | Person with an increased temperature
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| Afebrile | Person with a normal temperature
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| TAchycardia | Pulse over 100
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| Bradycardia | Pulse under 60
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| Normal adult respirations | 12-20
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| TAchypnea | Over 24 respitations per minute
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| Bradypnea | under 10 respirations per minute
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| Hyperventilation | Increased rate/ depth breathing
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| Hypoventilation | Decreased rate/ depth breathing
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| Cheyne-stokes | altered deep/ rapid breathing followed by apnea
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| Biots | Varying depth/ rate followed by period of apnea
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| 4 sites for assessing body temperature | Tympanic membrane Oral Rectal Axillary
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| 8 sites for assessing pulse | Radial (Wrist) Brachial (Arm) Coratid (neck) Temporal (Above ear) Femoral (Inner thigh) Popliteal (back of knee) Dorsalis pedis (instep of ankle) Posterior tibial (side of ankle)
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| 2 actions for assessing respirations | Inspection and Auscultation
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| 2 areas to assess BP | Brachial Artery and Popliteal Artery
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| Normal Temp C and F | 37 C and 98.6 F
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| Axillary temp newborn | 36.8 C
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| REctal temp age 1-3 | 37.7 C
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| Over age 70 C and F temp | 36 C and 96.8 F
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| Normal pulse teen and older | 60 - 100
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| Pulse newborn | 80 - 180
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| Pulse age 1 -3 | 80 140
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| Pulse age 6-8 | 75 - 120
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| Pulse age 10 | 75 - 110
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| Respirations Newborn | 30 - 80
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| Resp 1 - 3 | 20 - 40
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| Resp 6 - 8 | 15 - 25
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| REsp age 10 | 15 - 25
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| Respirations Teen | 15 - 20
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| Respirations Adult | 12 - 20
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| Respirations Over 70 | 15- 20
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| Blood Pressure Adult and Elderly | 120 / 80
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| BP Teens | 102 / 80
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| BP age 10 | 102 / 62
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| BP age 6-8 | 95 / 75
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| BP age 1 -3 | 90 / 55
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| BP newborn | 73 / 55
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| Adult Prehypertension | 120-139/ 80-89
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| Adult Stage I Hypertension | 140- 159/ 90- 99
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| Adult Stage II Hyperstension | Greater than 160/ Greater than 100
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| Patient teaching for temperature (4) | 1) 30 min after eating or smoking 2) Under side of tounge with mouth closed 3) Leave in place 2-3 min 4) Wash thermometer
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| patient teaching for Pulse (3) | 1) May need to take before medication 2) Need a watch with second hand 3) Teach how to find pulse and count for 1 min
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| Patient teaching for BP (2) | 1) May need to check for medications 2) Teach about cuff size and placement
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| Normal pulse for a newborn | 120- 160
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| Initial assessment when? | Shortly after arrival
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| Initial assessment Why? 2 | To establish a baseline and to identify problems
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| Focuses assessment looks at? | A specific problem or body system
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| 4 types of assessment | 1) Initial 2) Focused 3) Emergency 4) Time-lapsed
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| Emergency assessment identifies | Life-threatening problems
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| Time lapsed assessment | Compares curent status with a baseline
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| Medical assessment | Targets pathological conditions and their treatments
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| Nursing assessment | Target responses to health problems and diseases impact on the person
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| Objective data is (2) | observable and measureable
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| Objective data and others | It can be validated by another
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| Subjective data | Percieved only by the person affected
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| The 4 characteristics of Data | 1) Purposeful 2) Complete 3) Factual and Accurate 4) Relavent
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| 2 components of Nursing observation | 1) Nursing history 2) Physical assessment
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| Observation uses ( ) | The 5 senses
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| Interview skills are used in ? | The nursing history
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| 2 purposes of the nursing physical assessment | 1) Appraisal of health status 2) Identification of patient problems
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| Type of data used in the nursing physical assessment | Objective
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| What is the primary and best source of patient data? | The patient
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| Other than the patient name 4 sources of patient data | 1) Family and Significan others 2) the patient record 3) Other healthcare professionals 4) Nursing and other healthcare literature
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| The patient record provides information from ( ) | Different members of the health care team
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| Data Validation | The act of confirming and verifying data
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| The goal of data validation | Keep data free of error, bias, or misinterpretation
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| Invalid data may lead to ( ) | Inappropriate care
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| 2 times when data needs to be validated? | When there is a discrepancy between what the person is saying and what the nurse is observing and When data lacks objectivity
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| Significant patient data may lead to? | 1) Alerting other healthcare professionals of assessment changes 2) Increased frequency of assessment 3) Initiate changes in treatment
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| Critical changes require (time) | Immediate consultation
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