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ATI > ATI FUNDAMENTALS- VITAL SIGNS > Flashcards

ATI FUNDAMENTALS- VITAL SIGNS Flashcards

1
Q

VITAL SIGNS

A

A reflection of the body’s physiological function. Includes pulse, blood pressure, respiratory rate, oxygen saturation and sometimes pain level.

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2
Q

HOW ARE VITAL SIGNS USED THROUGH THE PROCESS OF PROVIDING CARE

A
  1. SERVES AS BASELINE
  2. IDENTIFY TRENDS/PATTERNS
  3. GUIDES Tx AND INTERVENTIONS
  4. HELPS EVALUATE OUTCOMES
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3
Q

WHAT TYPE OF DATA ARE VITAL SIGNS

A

OBJECTIVE

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4
Q

WHEN ARE VITAL SIGNS OBTAINED

A
  1. FIRST ENCOUNTER LIKE ARRIVAL
  2. INSTITUTION POLICY
  3. AFTER SURGERY/PROCEDURE
  4. Q4H OR Q8H
  5. ADMIN OF BLOOD PRODUCTS OR MEDS
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5
Q

WHEN MEASURING VS, THE NURSE SHOULD FOLLOW WHAT PROCEDURES

A
  1. INFECTION CONTROL GUIDELINES
  2. STANDARD PRECAUTIONS
  3. FACILITY POLICY
  4. HAND HYGIENE
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6
Q

BLOOD PRESSURE

A

AMOUNT OF PRESSURE EXERTED BY THE BLOOD WITHING THE CIRCULATORY SYSTEM

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7
Q

HOW IS BP MEASURED AND EXPRESSED

A

mmHg
SYSTOLIC/DIASTOLIC

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8
Q

SYSTOLIC BP

A

MAXIMUM AMOUNT OF PRESSURE EXERTED WHEN THE HEART CONTRAACTS AND FORCES BLOOD INTO THE AORTA

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9
Q

DIASTOLIC BP

A

MINIMUM AMOUNT OF PRESSURE EXERTED WHEN THE HEART IS RELAXED

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10
Q

BP IS A DIRECT REFLECTION OF

A

CARDIAC OUTPUT
BLOOD VOLUME
BLOOD VISCOSITY
VASCULAR ELASTICITY
DEGREE OF PERIPHERAL VASCULAR RESISTANCE

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11
Q

CARDIAC OUTPUT
CO

A

AMOUNT OF BLOOD PUMPED INTO THE CIRCULATORY SYSTEM BY THE HEART WITHIN ONE MINUTE

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12
Q

STROKE VOLUME
SV

A

AMOUNT OF BLOOD EJECTED BY THE VENTRICLE DURING ONE CONTRAACTION

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13
Q

CARDIAC OUTPUT EQUATION

A

CO = SV + HR

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14
Q

CARDIAC FACTORS INCREASE BP

A

INCREASED CARDIAC OUTPUT
INCREASED STROKE VOLUME
INCREASED HEART RATE
INCREASED BLOOD VOLUME
INCREASED VISCOSITY

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15
Q

BLOOD VISCOSITY

A

THICKNESS OF THE BLOOD

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16
Q

ELASTICITY

A

ABILITY OF VESSELS TO STRETCH AND COMPRESS THEN RETURN TO ORIGINAL SHAPE

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17
Q

DECREASE IN ELASTICITY INCREASES WHAT

A

RIGIDITY OF THE VESSEL WALL
INCREASES BP

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18
Q

peripheral vascular resistance

A

The total resistance to flow of blood in the vascular bed.

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19
Q

CONTRACTILITY

A

HEART’S ABILITY TO CONTRACT EFFICIENTLY

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20
Q

CONTRACTILITY IS INDICATED BY

A

EJECTION FRICTION AND MEASURED IN THE LEFT VENTRICLE VIA AN ECHOCARDIOGRAM

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21
Q

EJECTION FRACTION

A

the percentage of blood ejected with each contraction of the ventricles

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22
Q

WHAT DOES A DECREASE IN CONTRACTILITY DO

A

DECREASE CO
DECREASE BP
USUALLY FROM DECREASE O2 AND ELECTROLYTE IMBALANCE

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23
Q

PRELOAD

A

THE AMOUNT OF BLOOD INSIDE THE VENTRICLES BEFORE THEY CONTRACT

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24
Q

IF PRELOAD IS DECREASED, WHAT HAPPENS

A

SV AND BP DECREASE

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25
Q

AFTERLOAD

A

AMOUNT OF RESISTANCE OR CONSTRICTION, THAT THE HEART MUST OVERCOME TO EJECT THE BLOOD INTO THE SYSTEMIC CIRCULATION

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26
Q

INCREASE IN AFTERLOAD LEADS TO WHAT

A

HYPERTROPHY OF THE HEART
DECREASED CONTRACTILITY
HYPERTENSION

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27
Q

BLOOD PATHWAY OF DEOXYGENATED BLOOD

A

DEOXYGENATED BLOOD RETURNS FROM THE SYSTEMIC CIRCULATION TO THE HEART VIA IVC AND SVC –> ENTERS RIGHT ATRIUM –> THROUGH TRICUSPIC VALVE –> RIGHT VENTRICLE –> HEART CONTRACTION FORCES IT INTO THE PULMONARY ARTER AND INTO THE LUNGS

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28
Q

OXYGENATED BLOOD PATHWAY

A

RETURNS TO THE HEART VIA THE PULMONARY VEIN –> LEFT ATRIUM –> MITRAL VALVE –> LEFT VENTRICLE –> HEART CONTRACTION FORCES INTO THE AORTA THAT SUPPLIES THE SYSTEMIC CIRCULATION

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29
Q

WHAT TOOLS ARE NEEDED TO OBTAIN A MANUAL BP

A

SPHYGMOMANOMETER
STETHOSCOPE
*MANUAL IS MORE ACCURATE THAN ELECTRONIC

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30
Q

IF BP IS ABNORMAL WHEN MEASURED ELECTRONICALLY, WHAT SHOULD YOU DO?

A

OBTAIN MANUALLY

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31
Q

The nurse should select a cuff width that encircles approximately

A

80% of the client’s arm

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32
Q

CONSIDERATIONS PRIOR TO OBTAINING BP

A
  1. USUALLY SUPINE OR SEATED
  2. LEGS NOT CROSSED
  3. FEET FLAT ON FLOOR
  4. REST ARM ON FURNITURE
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33
Q

WHAT SHOULD YOU INFLATE THE BP CUFF TO

A

30 mmHg ABOVE EXPECTED SYSTOLIC PRESSURE VALUE

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34
Q

KOROTKOFF SOUNDS

A

A series sounds created by movement of blood through a partially compressed vessel during a manual blood pressure assessment.

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35
Q

ALTERNATIVE SITES FOR BP

A

THIGH

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36
Q

FALSE READINGS OF BP

A

CUFF IS TOO SMALL/LARGE
CUFF IS TOO LOOSE
ELEVATED IF ARM IS UNSUPPORTED

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37
Q

WHITE COAT SYNDROME

A

PHENOMENON WHERE CLIENT EXPERIENCES ANXIETY AND INCREASED BP WHEN IN HEALTH CARE SETTING
MUST BUILD RAPPORT AND ALLOW REST TO MINIMIZE BP EFFECTS

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38
Q

Intrinsic factors include

A

those that are not modifiable, such as age, ethnicity, genetics, and natural hormonal variations.
For instance, blood pressure gradually increases throughout childhood, reaching adult levels during adolescence. It then tends to increase slightly throughout adulthood until older adulthood, when it decreases slightly.

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39
Q

Extrinsic factors are

A

external factors that a client can control to some extent. They include weight, use of stimulants such as caffeine or nicotine, medications, sodium intake, stress, and activity level.

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40
Q

FACTORS INCREASING BP

A
  1. ANXIETY/FEAR
  2. NICOTINE
  3. STIMULANTS
  4. PAIN
  5. FEVER
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41
Q

FACTORS DECREASING BP

A

HYPOGLYCEMIA
HEART FAILURE

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42
Q

Hypertension is

A

a blood pressure that is above the expected reference range.

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43
Q

MOST FREQUENT CAUSE OF HYPERTENSION

A
  1. THICKENING OF ARTERIAL VESSELS WALLS AND DECREASE IN THEIR ELASTICITY WHICH INCREASES PERIPHERAL VASCULAR RESISTANT
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44
Q

HOW DO WE ARRIVE AT A DIAGNOSIS OF HYPERTENSION

A

2 ELEVATED READINGS TAKEN ON 2+ SEPARATE OCCASSIONS

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45
Q

NORMAL BP LEVEL

A

LESS THAN 120/ LESS THAN 80

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46
Q

ELEVATED BP LEVEL

A

120-129 / LESS THAN 80
BOTH REQUIRED

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47
Q

HYPERTENSION STAGE 1

A

130-139/80-89
ONE OR THE OTHER

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48
Q

HYPERTENSION STAGE 2

A

140+/9+
BOTH REQUIRED

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49
Q

HYPERTENSIVE CRISIS

A

HIGHER THAN 180 / HIGHER THAN 120
CAN BE EITHER OR BOTH

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50
Q

NEWBORN - FULL TERM - BP

A

64/41

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51
Q

MALE TODDLER BP

A

85-91 / 37-46

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52
Q

FEMALE TODDLER BP

A

86-89/40-49

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53
Q

PRESCHOOLER MALE BP

A

91-98/46-53

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54
Q

PRESCHOOLER FEMALE BP

A

89-93/49-54

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55
Q

SCHOOL AGE MALE BP

A

96-106/55-62

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56
Q

SCHOOL AGE FEMALE BP

A

94-105/56-62

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57
Q

ADOLESCENT BP

A

LESS THAN 120/80

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58
Q

LIFESTYLE INTERVENTIONS FOR HYPERTENSION

A

EXERCISE
STRESS REDUCTION
LOW SODIUM DIET
WEIGHT LOSS

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59
Q

HYPOTENSION

A

A blood pressure that is below the expected reference range as determined by a client’s usual baseline measurement

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60
Q

WHAT IS CONSIDERED HYPOTENSION IF WE HAVE NO BASELINE

A

LESS THAN 90 / LESS THAN 60

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61
Q

CAUSES OF HYPOTENSION

A

DEHYDRATION
BLOOD LOSS
SHOCK
SIGNIFICANT ILLNESS
SHOCK

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62
Q

S/S OF HYPOTENSION

A

DIZZINESS
NAUSEA
BLURRED VISION
INCREASED PULSE
FATIGUE

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63
Q

S/S OF SHOCK

A

COLD
PALE
RAPID RR
WEAK AND RAPID PULSE

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64
Q

INTERVENTIONS FOR SHOCK

A

RAPID INFUSION IV FLUIDS OR BLOOD
ADMIN MEDS TO INCREASE BP AND CONTRACTILITY

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65
Q

ORTHOSTATIC HYPOTENSION

A

a drop in blood pressure that occurs when a client rises to a sitting or standing position.

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66
Q

ORTHOSTATIC HYPOTENSION CAN BE CAUSED BY

A

dehydration, hypotension, heart failure, or a disorder of the central nervous system.

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67
Q

S/S OF ORTHOSTATIC HYPOTENSION

A

FAINTNESS
DIZZINESS
INCREASED FALL RISK

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68
Q

WHAT IS CONSIDERED ORTHOSTATIC HYPOTENSION

A

DROP IN SYSTOLIC PRESSURE OF AT LEAST 20 OR DIASTOLIC OF AT LEAST 10 WITHING 1 MINUTE

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69
Q

TO DETERMINE ORTHOSTATIC HYPOTENSION, YOU SHOULD RECHECK BP AT WHAT TIMES

A

1 MIN
AND
3 MIN

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70
Q

INTERVENTIONS TO INCREASE BP

A

INCREASE FLUIDS
IV FLUIDS
COMPRESSION STOCKINGS
CHANGE POSITIONS SLOWLY
SLIGHTLY ELEVATE HOB WHEN SLEEPING
AVOID A LYING OR SEATED POSITION OF EXTENDED TIME

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71
Q

S/S OF HYPOTENSION

A

DECREASED CO
ACTIVITY INTOLERANCE
CHEST PAIN W/ EXERTION

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72
Q

PATIENT EDUCATION ON HYPOTENSION

A

RISK OF DIZZINESS AND FALLING
CHANGE POSITIONS SLOWLY
AVOID EXTREME TEMPS
STAY HYDRATED

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73
Q

PRACTICE LABELING HEART IN THE FUNDAMENTALS VS PAGE 2

A
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74
Q

A nurse is discussing factors affecting blood pressure with an assistive personnel. Which of the following factors should the nurse identify as potential causes for an increase in a client’s blood pressure? (Select all that apply.)

A
Anxiety

B
Use of nicotine

C
Young adult age

D
Obesity

E
Fear

A

A, B, D, E

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75
Q

Name the four stages of hypertension, including the blood pressure values that define each stage.

A

Elevated: when the systolic pressure is 120 to 129 mm Hg and the diastolic pressure is less than 80 mm Hg Stage I hypertension: when the systolic pressure is 130 to 139 mm Hg, or the diastolic pressure is 80 to 89 mm Hg Stage II hypertension: when the systolic pressure is 140 mm Hg or greater or the diastolic pressure is 90 mm Hg or greater Hypertensive crisis: when the systolic pressure is greater than 180 mm Hg and/or the diastolic pressure is greater than 120 mm Hg

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76
Q

A nurse is caring for a client who reports dizziness when standing up. The client’s blood pressure after lying supine for 15 minutes is 136/86 mm Hg in the left arm. Which of the following findings would indicate the client is experiencing orthostatic hypotension?

A
B/P 128/84 mm Hg, left arm, sitting for 2 minutes

B
B/P 120/78 mm Hg, left arm, immediately after sitting

C
B/P 114/72 mm Hg, left arm, immediately after standing

D
B/P 124/80 mm Hg, left arm, standing for 3 minutes

A

C

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77
Q

WHAT RESULTS IN A FALSELY HIGH BP MSMT

A

BP CUFF TO LOOSE
OBTAINED RIGHT AFTER NICOTICE

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78
Q

WHAT WOULD CAUSE FALSELY LOW BP LEVELS

A
  1. LEAVING ARM UNSUPPORTED
  2. CUFF IS TOO SMALL
  3. CUFF IS TOO LARGE
  4. CUFF TOO LOOSE
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79
Q

PULSE

A

RHYTHMIC DILATION OF THE ARTERIES AND PULSATION OF BLOOD FLOW THAT OCCURS WITH EACH CONTRACTION OF THE VENTRICLE

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80
Q

SINOATRIAL NODE
SA NODE

A

PACEMAKER OF THE HEART
SMALL GROUP OF SPECIAL CELLS IN RIGHT ATRIUM
PRODUCES ELECTRICAL IMPULSES THAT TRAVEL TO AV NODE NEART THE VENTRICLES THAT CAUSE THE HEART MUSCLE TO CONTRACT

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81
Q

BIRTH TO 28 DAYS
HR

A

110-160 BPM

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82
Q

1 MONTH TO 1 YEAR
HR

A

90-160 BPM

83
Q

1 YEAR TO 3 YEAR
HR

A

80-140 BPM

84
Q

3 YEAR TO 6 YEAR
HR

A

70-120 BPM

85
Q

6 YEAR TO 12 YEAR
HR

A

60-110 BPM

86
Q

12 YEAR TO 20 YEAR
HR

A

50-100 BPM

87
Q

20 YEAR +
HR

A

60-100 BPM

88
Q

INFLUENCING FACTORS OF HR

A

BODY POSITION, AGE, ACTIVITY LEVEL, HEALTH CONDITIONS, BODY TEMP, MEDS, UNDERACTIVE THYROID GLAND CAN EVEN CAUSE DECREASE

89
Q

TACHYCARDIA

A

HR GREATER THAN 100/MIN IN ADULT

90
Q

CAUSES OF TACHYCARDIA

A

EXERCISE, ANXIETY, CERTAIN MEDS, CAFFEINE, NICOTINE, HEART ABNORMALITIES

91
Q

MANAGING TACHYCARDIA

A

RELAXATION TECHNIQUES- MEDITATION, YOGA, GUIDED IMAGERY
VSLSALVA MANEUVER
SMOKING CESSATION

92
Q

VALSALVA MANEUVER

A

TO ELICIT VASOVAGAL RESPONSE BY STIMULATION OF VAGUS NERVE
BEAR DOWN LIKE BM TO STIMULATE THE PARASYMPATHETIC NERVOUS SYSTEM TO DECREASE HR

93
Q

BRADYCARDIA

A

ADULT HR LESS THAN 60 BPM
*EXPECTED IN PHYSICALLY FIT

94
Q

S/S OF BRADYCARDIA

A

DIZZINESS
FATIGUE
SHORTNESS OF AIR
CHEST PAIN
CONFUSION

95
Q

CAUSES OF BRADYCARDIA

A

CONGENITAL HEART ABNORMALITIES
HEART FAILURE
HEART MUSCLE DAMAGE
HYPOTHYROIDISM

96
Q

MANAGING BRADYCARDIA

A

CHANGE POSITIONS SLOWLY
TAKE MEDS AS PRESCRIBED
KEEP ALL APPOINTMENTS

97
Q

ARRHYTHMIA

A

IRREGULAR RHYTHM OR PULSE RATE

98
Q

S/S OF ARRYTHMIA

A

*SOME GO UNNOTICED
SOB
DIZZINESS

99
Q

IF ABNORMAL PULSE, COUNT APICAL FOR HOW LONG

A

1 MINUTE

100
Q

WHERE TO PALPATE AND AUSCULTATE APICAL PULSE

A

APEX OF THE HEART
FIFTH INTERCOSTAL SPACE AT MIDCLAVICULAR LINE
*CHILDREN UNDER 7, IT IS LOCATED AT 4TH INTERCOSTAL TO THE LEFT OF THE STERNUM

101
Q

S1

A

DULL
LOW PITCHED
LUB
USE BELL OF STETHO

102
Q

S2

A

SHORTER
HIGHER PITCHED
DUB
USE DIAPHRAGM OF STETHO

103
Q

TEMPORAL PULSE

A

OVER TEMPORAL ARTERY AT TEMPLE

104
Q

BRACHIAL PULSE

A

OVER BRACHIAL ARTERY
USED TO ASSESS QUALITY OF PERFUSION
PALPATED IN THE ANTECUBITAL SPACE

105
Q

RADIAL PULSE

A

RADIAL ARTERY
PALPATED OVER THE GROOVE ALONG THE THUMB SIDE OF INNTER WRIST

106
Q

FEMORAL PULSE

A

OVER FEMORAL ARTERY
IN GROIN ON EITHER SIDE OF GENITALS
USED TO ASSESS PERFUSION QUALITY

107
Q

POPLITEAL PULSE

A

POPLITEAL ARTERY LOCATED BEHIND KNEE
USED TO ASSESS PERFUSION QUALITY

108
Q

DORSALIS PEDIC PULSE

A

HEART WITH DOPPLER OR PALPATED OVER DORSALIS PEDIS ARTER LOCATED ON THE DORSAL SIDE OF FOOT
ASSESS PERFUSION QUALITY

109
Q

POSTERIOR TIBIAL PULSE

A

OVER POSTERIOR TIBIAL ARTERY
MEDIAL SIDE OF ANKLE
ASSESS PERFUSION QUALITY

110
Q

MOST COMMON SITE TO PALPATE PULSE

A

RADIAL

111
Q

WHEN TO ASSESS PERIPHERAL PULSES

A

PROCEDURE THAT COULD AFFECT CIRCULATION
IMPAIRED PERIPHERAL BLOOD FLOW SUCH AS COOL SKIN TEMP OR SKIN COLOR ALTERATION

112
Q

PULSE DEFICIT

A

DIFFERENCE BETWEEN APICAL AND PERIPHERAL PULSE IN 1 MINUTE

113
Q

CAUSES OF PULSE DEFICIT

A

AORTIC RUPTURE
CAD
ATRIAL FIBRILLATION

114
Q

HOW MANY PEOPLE TO ASSESS PULSE DEFICIT

A

2 NURSES COUNTING AT THE SAME TIME

115
Q

PULSE RATINGS

A

0 = ABSENT
+1 = WEAK
+2 = NORMAL
+3 = STRONG
+4 = BOUNDING

116
Q

EXPECTED PULSE FINDINGS

A

OBLITERATED WITH SIGNIFICAN PRESSURE IF STRONG
PALPABLE
NOT WEAK OR BOUNDING
EQUAL BILATERALLY

117
Q

WHAT DO YOU DO WHEN A PERIPHERAL PULSE IS NONPALPABLE

A

USE DOPPLER ULTRASOUND STETHO TO AUSCULTATE

118
Q

A nurse is reviewing the medical records for a group of clients. Which of the following clients should the nurse identify as being at risk for experiencing tachycardia?

A
24-year-old long-distance runner who is walking in the hallway of the unit

B
38-year-old client who has a fever due to an infection

C
51-year-old client who received an opioid analgesic 2 hours ago

D
66-year-old client who has heart failure

A school nurse is reviewing the health records for a group of students who recently had a physical examination. Which of the following students should the nurse identify as having a pulse rate outside of the expected reference range? (Select all that apply.)

A
6-year-old who has a pulse rate of 106/min

B
17-year-old who has a pulse rate of 102/min

C
3-year-old who has a pulse rate of 96/min

D
10-year-old who has a pulse rate of 118/min

E
15-year-old who has a pulse rate of 40/min

A nurse is caring for an adult client who has bradycardia. Which of the following physical manifestations of bradycardia should the nurse expect?

A
Vomiting

B
Dilated pupils

C
Flushed face

D
Dizziness

A nurse is discussing tachycardia with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as exhibiting tachycardia?

A
Newborn who has a pulse of 158/min

B
Preschooler who has a pulse of 142/min

C
Adolescent who has a pulse of 98/min

D
Older adult who has a pulse of 88/min

A nurse is monitoring the pulse rates for a group of clients. Identify if the pulse is expected (within the expected reference range) or unexpected (outside of the expected reference range) for each of the following clients. (Drag each client description to the desired category. If you select the wrong category, the description will automatically move to the correct category.)

Expected finding

A nurse is reviewing the medical records for a group of clients. Which of the following clients should the nurse identify as being at risk for experiencing tachycardia?

A
24-year-old long-distance runner who is walking in the hallway of the unit

B
38-year-old client who has a fever due to an infection

C
51-year-old client who received an opioid analgesic 2 hours ago

D
66-year-old client who has heart failure

A

B

119
Q

A school nurse is reviewing the health records for a group of students who recently had a physical examination. Which of the following students should the nurse identify as having a pulse rate outside of the expected reference range? (Select all that apply.)

A
6-year-old who has a pulse rate of 106/min

B
17-year-old who has a pulse rate of 102/min

C
3-year-old who has a pulse rate of 96/min

D
10-year-old who has a pulse rate of 118/min

E
15-year-old who has a pulse rate of 40/min

A

D
E

120
Q

A nurse is caring for an adult client who has bradycardia. Which of the following physical manifestations of bradycardia should the nurse expect?

A
Vomiting

B
Dilated pupils

C
Flushed face

D
Dizziness

A

D

121
Q

A nurse is discussing tachycardia with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as exhibiting tachycardia?

A
Newborn who has a pulse of 158/min

B
Preschooler who has a pulse of 142/min

C
Adolescent who has a pulse of 98/min

D
Older adult who has a pulse of 88/min

A

B

122
Q

BODY TEMPERATURE

A

MEASUREMENT OF BALANCE OF HEAT PRODUCED AND HEAT LOST TO ENVIRONMENT
MEASURE IN DEGREES

123
Q

CORE TEMP

A

TEMP OF THE DEEP TISSUES WITHIN THE BODY

124
Q

SURFACE TEMP

A

TEMP OF THE SKIN, FAT, SUBQ TISSUE

125
Q

NORMAL BODY TEMP

A

37 C OR 98.6 F
CAN RANGE FROM 37-39 C OR 96.8-100.4 F

126
Q

EXPECTATION OF TEMP IN ELDERLY

A

SLIGHTLY LOWER

127
Q

WHEN DO WE HAVE OUR LOWEST TEMP

A

IN THE MORNING.

128
Q

FACTORS OF TEMP

A

EXERCISE OR STRESS WILL INCREASE
COOL ENVIRONMENT WILL DECREASE

129
Q

THERMOREGULATION

A

BODY’S NATURAL MECHANISM FOR BALANCING BODY TEMP

130
Q

CONDUCTION

A

LOSS OF HEAT DUE TO DIRECT CONTACT WITH A COOLER SURFACE
HOW BODY LOSES HEAT TO ENVIRONMENT

131
Q

CONVECTION

A

LOSS OF HEAT DUE TO AIR CURRENTS

132
Q

EVAPORATION

A

LOSS OF HEAT VIA GASES FROM LUNGS OR DRYING OF SWEAT FROM THE SKIN

133
Q

RADIATION

A

LOSS OF HEAT DUE TO INDIRECT CONTACT WITH OR BEING IN CLOSE PROXIMITY TO A COLER SURFACE

134
Q

WHAT CAUSES A FEVER

A

UPWARD SHIFT OF BODY’S NATURAL SET POINT IN THE HYPOTHALAMUS GLAND

135
Q

WHAT TEMP IS CONSIDERED A FEVER

A

38 C
100.4 F

136
Q

S/S OF FEVER

A

FLUSHED FACE, DIAPHORETIC, SKIN THAT FEELS HOT, EXHIBIT TACHYCARDIA, INCREASED RR

137
Q

FEBRILE

A

WHAT A PATIENT WITH A FEVER IS CONSIDERED

138
Q

AFEBRILE

A

WHAT A PATIENT WHOSE FEVER HAS DISSIPATED IS CONSIDERED

139
Q

HYPERTHERMIA

A

INCREASED TEMP DUE TO INABILITY TO STOP HEAT PRODUCTION OR TO STIMULATE HEAT LOSS

140
Q

WHAT CAUSES HYPERTHERMIA

A

INABILITY FOR HYPOTHALAMUS TO MAINTAIN REGULATION OF TEMP

141
Q

S/S OF HYPERTHERMIA

A

DIZZINESS, WEAKNESS, THIRST, NAUSEA

142
Q

IF LEFT UNTREATED, HYPERTHERMIA CAN CAUSE

A

HYPOTENSION, SYNCOPE, CONFUSION, TACHYCARDIA, IMPAIRED COORDINATION, ORGAN FAILURE, OR DEATH

143
Q

Tx OF HYPERTHERMIA

A

COOLER ENVIRONMENT
REMOVE EXCESS CLOTHING
COLD PACKS TO NECK, AXILLAE, AND GROIN
FAN
IV FLUIDS

144
Q

HYPOTHERMIA

A

DECREASE IN CORE BODY TEMP DUE TO EXTENDED EXPOSURE TO COLD OR INABILITY TO PRODUCE HEAT

145
Q

S/S OF HYPOTHERMIA

A

SHIVERING, DECREASED MOTOR SKILLS, IMPAIRED PERIPHERAL PERFUSION, CONFUSION, POOR CONCENTRATION, DILATED PUPILS, LOSS OF CONSCIOUSNESS

146
Q

SEVERE HYPOTHERMIA

A

MEDICAL EMERGENCY
LOSS OF DEEP TENDON REFLEXES
COMA
HIGH RISK FOR CARDIAC ARREST

147
Q

Tx OF HYPOTHERMIA

A

WARMING MAT/BLANKET
INFANTS IN RADIANT WARMER
INCREASE ROOM TEMP
ADD LAYER OF CLOTHING
HAT/CAP ON HEAD
WARMED IV FLUIIDS

148
Q

5 COMMON SITES TO ASSESS BODY TEMP

A

ORAL, TYMPANIC, TEMPORAL, AXILLARY, RECTAL

149
Q

ORAL TEMP PROS

A

EASILY ACCESSIBLE
ACCURATE TO SURFACE TEMP

150
Q

ORAL TEMP CONS

A

EXPOSURE TO BODY FLUIDS
INACCURATE IF PT ATE, DRANK, SMOKED W/IN 30 MINUTES
UNUSABLE FOR NEWBORNS/INFANTS/YOUNG CHILDREN BECAUSE CAN’T FOLLOW COMMANDS

151
Q

TYMPANIC TEMP PROS

A

EASILY ACCESSIBLE
RAPID RESULT
ACCURATE TO CORE TEMP
NOT ALTERED BY ENVIRONMENTAL TEMP

152
Q

TYMPANIC TEMP CONS

A

INACCURATE IF CERUMEN OR EAR INFECTION
DIFFICULT TO OBTAIN ACCURATE RESULT IN NEWBONS/INFANTS/CHILDREN YOUNGER THAN 3
REQUIRES HEARING AID REMOVAL

153
Q

TEMPORAL TEMP PROS

A

EASILY ACCESSIBLE
RAPID RESULT
NO RISK OF INJURY
GOOD FOR ALL AGE GROUPS
REFLECTS RAPID CHANGES IN CORE TEMP

154
Q

TEMPORAL TEMP CONS

A

INACCURATE IF HEAD COVERING
CAN BE DISTORTED IF MOISTURE ON SKIN LIKE SWEAT

155
Q

AXILLARY TEMP PROS

A

GOOD FOR ALL AGE GROUPS
NO RISK OF INJURY

156
Q

AXILLARY TEMP CONS

A

MORE TIME TO READ
NOT GOOD FOR RAPID CORE TEMP CHANGES
RESULTS ALTERED BY ENVIRONMENT TEMPS

157
Q

RECTAL TEMP PROS

A

RELIABLE RESULT

158
Q

RECTAL TEMP CONS

A

RISK OF INJURY TO MUCOSA
ALTERED W/ PRESENCE OF STOOL
UNPLEASANT FOR CLIENTS
DO NOT USE IF DIARRHEA, HEMORRHOIDS, RECTAL SURGERY, COAGULATION DISORDERS

159
Q

TYPES OF THERMOMETERS

A

ELECTRONIC
TYMPANIC
TEMPORAL
CHEMICAL DOT
TEMP SENSITIVE TAPE/PATCH

160
Q

HOW FAR TO INSERT RECTAL THERMOMETER

A

1/2 INCH TOWARD UMBILICUS
DO NOT FORCE

161
Q

What are some nursing interventions you can implement to address his fever?

A

Nursing interventions to address Mr. Ricci’s fever include the following. Remove blankets, hats, and clothing except for a single light layer. Encourage Mr. Ricci to drink cool fluids or eat ice chips frequently. Administer an antipyretic medication. Sponge Mr. Ricci’s skin with tepid water. Enhance heat loss via convection by placing a fan near Mr. Ricci. Administer antibiotics. Administer IV fluids. Decrease the temperature of the room.

162
Q

RESPIRATION

A

THE ACT OF BREATHING

163
Q

2 PHASES OF RESPIRATION

A

INSPIRATION
EXPIRATION

164
Q

INSPIRATION

A

intake of air by the lungs so as to oxygenate body tissues and support cellular function.

165
Q

WHAT HAPPENS TO THE OXYGEN THAT ENTERS THE LUNGS DURING INSPIRATION

A

transported through the bronchi and bronchioles to the alveoli. Gas exchange occurs via diffusion between the alveolar air and the pulmonary capillaries. Carbon dioxide, the waste product of this exchange, is expelled from the lungs during expiration.

166
Q

MECHANICAL FACTORS OF RESPIRATION

A
  1. LUNGS CANNOT SELF INFLATE
  2. LUNGS EXPAND WHEN THE THORACIC CAVITY EXPANDS
  3. EXPANSION OCCURS DURING CONTRACTION OF DIAPHRAGM AND INTERCOSTAL MUSCLES THAT PULL THE RIBS UP AND OUT
167
Q

The nurse can also assess a client’s respiratory rate and rhythm by

A

auscultating the client’s lungs with a stethoscope.

168
Q

RESPIRATORY RATE

A

the number of sets of inspirations and expirations to determine the rate of breaths per minute

169
Q

HOW LONG SHOULD A NURSE OBSERVE RESPIRATIONS

A

HEALTHY- 30 SECONDS AND MULTIPLY BY 2
ALTERED STATUS- 1 MINUTE

170
Q

EUPNEA

A

RR WITHIN EXPECTED RANGE

171
Q

BIRTH TO 28 DAYS
RR

A

30-60/MIN

172
Q

1 MONTH - 1 YEAR
RR

A

25-60/MIN

173
Q

1 YEAR - 3 YEARS
RR

A

25-30/MIN

174
Q

3 YRS - 6 YRS
RR

A

20-25 / MIN

175
Q

6 YRS - 12 YRS
RR

A

20-25/MIN

176
Q

12 YRS - 20 YRS
RR

A

16-20/MIN

177
Q

20 YRS +
RR

A

12-20/MIN

178
Q

TACHYPNEA

A

a respiratory rate that is higher than the expected reference range. A client experiencing tachypnea may also exhibit shallow respirations.

179
Q

S/S OF TACHYPNEA

A

DIZZINESS
TINGLING IN THE HANDS

180
Q

CAUSES OF TACHYPNEA

A

INCREASED PHYSICAL ACTIVITY
PAIN
ANXIETY
RESPIRATORY INFECTION LIKE PNEUMONIA
CHRONIC LUNG DISEASES
ASTHMA

181
Q

BRADYPNEA

A

respiratory rate that is lower than the expected reference range.

182
Q

S/S OF BRADYPNEA

A

DIZZINESS
FATIGUE
WEAKNESS
CONFUSION
IMPAIRED COORDINATION

183
Q

CAUSES OF BRADYPNEA

A

INCREASED INTRACRANIAL PRESSURE
HYPOTHYROIDISM
SHOCK
ALCOHOL TOXICITY
OPIOIDS
SEDATIVES
MORBID OBESITY

184
Q

APNEA

A

A CESSATION OF RESPIRATIONS

185
Q

CAUSES OF APNEA

A

OPIOID TOXICITY
TRAUMA
NEUROLOGIC DYSFUNCTION

186
Q

CHEYNE-STOKES RESPIRATIONS

A

IRREGULAR AND CONSIST OF A CYCLING PATTERN OF BREATHS RANGING FROM SHALLOW TO DEEP, FOLLOWED BY PERIODS OF HYPERVENTILATION, THEN AN EPISODE OF APNEA

187
Q

CAUSES OF CHEYNE STOKES RESPIRATIONS

A

INCREASED INTRACRANIAL PRESSURE
BRAIN TUMOR
STROKE
HEART FAILURE
END OF LIFE

188
Q

KUSSMAUL RESPIRATIONS

A

REGULAR RHYTHM BUT ABNORMALLY DEEP AND RAPID

189
Q

CAUSES OF KUSSMAUL RESPIRATIONS

A

SEVERE METABOLIC ACIDOSIS
DIABETIC KETOACIDOSIS
SEVERE KIDNEY DISEASE

190
Q

QUALITY AKA CHARACTER OF RESPIRATIONS

A

amount of effort a client must exert to breathe, as well as any audible sounds produced during breathing.

191
Q

RESPIRATORY RETRACTIONS

A

involve the use of accessory muscles in the neck, substernally, subcostally, or in the intercostal areas, which causes the tissue to be pulled inward during inspiration.

192
Q

OXYGEN SATURATION
SaO2

A

estimated amount of oxygen bound to the hemoglobin molecule in red blood cells. Measurement of SaO2 by pulse oximetry is referred to as SpO2.

193
Q

SpO2 s an indication of

A

the amount of oxygen being transported to body tissues and is expressed as a percentage with an expected reference range of 95% to 100%.

194
Q

Prior to measuring a client’s oxygen saturation level, the nurse must choose a site that has

A

adequate capillary refill. A capillary refill time of less than 2 seconds indicates good perfusion, which can help ensure a reliable result.

195
Q

SITES FOR MEASURING OXYGEN SATURATION

A

FINGER
FOOT, WRIST FOR NEWBORNS
EARLOBE
ADHESIVE PROBE

196
Q

HOW TO GET ACCURATE SpO2

A

FINGER IS DRY
NO DARK NAIL POLISH
NO ARTIFICIAL NAILS
MAKE SURE THE PULSE ON THE SCREEN MATCHES THE RADIAL PULSE WHEN USING AN ADHESIVE PROBE

197
Q

WHAT CAN CAUSE A DECREASE OF SaO2

A

CHRONIC LUNG DISEASE
HYPOTHERMIA
DECREASE PERFUSION
POOR CARDIAC OUTPUT

198
Q

DYSPNEA

A

SHORTNESS OF BREATH

199
Q

S/S OF LOW SaO2

A

DYSPNEA
COUGH
TACHYCARDIA
CONFUSION

200
Q

HYPOXIA

A

LACK OF OXYGEN TO TISSUES
CAN DECREASE MENTAL ALERTNESS AND CONFUSION

201
Q

Tx OF DECREASED SaO2

A

DEPENDS ON UNDERLYING ETIOLOGY
SIT CLIENT UP
TAKE DEEP BREATAHS AND COUGH
SUPPLEMENTAL 2
MEDICATIONS- BRONCHODILATORS

202
Q

A nurse is monitoring respirations for a group of clients. Which of the following clients should the nurse identify as exhibiting tachypnea? (Select all that apply.)

A
2-week-old newborn who has a rate of 56/min

B
6-year-old child who has a rate of 28/min

C
17-year-old adolescent who has a rate of 24/min

D
2-year-old toddler who has a rate of 48/min

E
9-year-old child who has a rate of 20/min

A

B, C, D

203
Q
A

ATI (10 decks)

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