Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

WHAT TYPE OF DATA ARE VITAL SIGNS

A

OBJECTIVE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

BLOOD PRESSURE

A

AMOUNT OF PRESSURE EXERTED BY THE BLOOD WITHING THE CIRCULATORY SYSTEM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

HOW IS BP MEASURED AND EXPRESSED

A

mmHg
SYSTOLIC/DIASTOLIC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

SYSTOLIC BP

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

DIASTOLIC BP

A

MINIMUM AMOUNT OF PRESSURE EXERTED WHEN THE HEART IS RELAXED

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

BP IS A DIRECT REFLECTION OF

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

CARDIAC OUTPUT
CO

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

STROKE VOLUME
SV

A

AMOUNT OF BLOOD EJECTED BY THE VENTRICLE DURING ONE CONTRAACTION

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

CARDIAC OUTPUT EQUATION

A

CO = SV + HR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

CARDIAC FACTORS INCREASE BP

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

BLOOD VISCOSITY

A

THICKNESS OF THE BLOOD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

ELASTICITY

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

DECREASE IN ELASTICITY INCREASES WHAT

A

RIGIDITY OF THE VESSEL WALL
INCREASES BP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

peripheral vascular resistance

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

CONTRACTILITY

A

HEART’S ABILITY TO CONTRACT EFFICIENTLY

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

CONTRACTILITY IS INDICATED BY

A

EJECTION FRICTION AND MEASURED IN THE LEFT VENTRICLE VIA AN ECHOCARDIOGRAM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

EJECTION FRACTION

A

the percentage of blood ejected with each contraction of the ventricles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

WHAT DOES A DECREASE IN CONTRACTILITY DO

A

DECREASE CO
DECREASE BP
USUALLY FROM DECREASE O2 AND ELECTROLYTE IMBALANCE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

PRELOAD

A

THE AMOUNT OF BLOOD INSIDE THE VENTRICLES BEFORE THEY CONTRACT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

IF PRELOAD IS DECREASED, WHAT HAPPENS

A

SV AND BP DECREASE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
AFTERLOAD
AMOUNT OF RESISTANCE OR CONSTRICTION, THAT THE HEART MUST OVERCOME TO EJECT THE BLOOD INTO THE SYSTEMIC CIRCULATION
26
INCREASE IN AFTERLOAD LEADS TO WHAT
HYPERTROPHY OF THE HEART DECREASED CONTRACTILITY HYPERTENSION
27
BLOOD PATHWAY OF DEOXYGENATED BLOOD
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
28
OXYGENATED BLOOD PATHWAY
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
29
WHAT TOOLS ARE NEEDED TO OBTAIN A MANUAL BP
SPHYGMOMANOMETER STETHOSCOPE *MANUAL IS MORE ACCURATE THAN ELECTRONIC
30
IF BP IS ABNORMAL WHEN MEASURED ELECTRONICALLY, WHAT SHOULD YOU DO?
OBTAIN MANUALLY
31
The nurse should select a cuff width that encircles approximately
80% of the client’s arm
32
CONSIDERATIONS PRIOR TO OBTAINING BP
1. USUALLY SUPINE OR SEATED 2. LEGS NOT CROSSED 3. FEET FLAT ON FLOOR 4. REST ARM ON FURNITURE
33
WHAT SHOULD YOU INFLATE THE BP CUFF TO
30 mmHg ABOVE EXPECTED SYSTOLIC PRESSURE VALUE
34
KOROTKOFF SOUNDS
A series sounds created by movement of blood through a partially compressed vessel during a manual blood pressure assessment.
35
ALTERNATIVE SITES FOR BP
THIGH
36
FALSE READINGS OF BP
CUFF IS TOO SMALL/LARGE CUFF IS TOO LOOSE ELEVATED IF ARM IS UNSUPPORTED
37
WHITE COAT SYNDROME
PHENOMENON WHERE CLIENT EXPERIENCES ANXIETY AND INCREASED BP WHEN IN HEALTH CARE SETTING MUST BUILD RAPPORT AND ALLOW REST TO MINIMIZE BP EFFECTS
38
Intrinsic factors include
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.
39
Extrinsic factors are
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.
40
FACTORS INCREASING BP
1. ANXIETY/FEAR 2. NICOTINE 3. STIMULANTS 4. PAIN 5. FEVER
41
FACTORS DECREASING BP
HYPOGLYCEMIA HEART FAILURE
42
Hypertension is
a blood pressure that is above the expected reference range.
43
MOST FREQUENT CAUSE OF HYPERTENSION
1. THICKENING OF ARTERIAL VESSELS WALLS AND DECREASE IN THEIR ELASTICITY WHICH INCREASES PERIPHERAL VASCULAR RESISTANT
44
HOW DO WE ARRIVE AT A DIAGNOSIS OF HYPERTENSION
2 ELEVATED READINGS TAKEN ON 2+ SEPARATE OCCASSIONS
45
NORMAL BP LEVEL
LESS THAN 120/ LESS THAN 80
46
ELEVATED BP LEVEL
120-129 / LESS THAN 80 BOTH REQUIRED
47
HYPERTENSION STAGE 1
130-139/80-89 ONE OR THE OTHER
48
HYPERTENSION STAGE 2
140+/9+ BOTH REQUIRED
49
HYPERTENSIVE CRISIS
HIGHER THAN 180 / HIGHER THAN 120 CAN BE EITHER OR BOTH
50
NEWBORN - FULL TERM - BP
64/41
51
MALE TODDLER BP
85-91 / 37-46
52
FEMALE TODDLER BP
86-89/40-49
53
PRESCHOOLER MALE BP
91-98/46-53
54
PRESCHOOLER FEMALE BP
89-93/49-54
55
SCHOOL AGE MALE BP
96-106/55-62
56
SCHOOL AGE FEMALE BP
94-105/56-62
57
ADOLESCENT BP
LESS THAN 120/80
58
LIFESTYLE INTERVENTIONS FOR HYPERTENSION
EXERCISE STRESS REDUCTION LOW SODIUM DIET WEIGHT LOSS
59
HYPOTENSION
A blood pressure that is below the expected reference range as determined by a client’s usual baseline measurement
60
WHAT IS CONSIDERED HYPOTENSION IF WE HAVE NO BASELINE
LESS THAN 90 / LESS THAN 60
61
CAUSES OF HYPOTENSION
DEHYDRATION BLOOD LOSS SHOCK SIGNIFICANT ILLNESS SHOCK
62
S/S OF HYPOTENSION
DIZZINESS NAUSEA BLURRED VISION INCREASED PULSE FATIGUE
63
S/S OF SHOCK
COLD PALE RAPID RR WEAK AND RAPID PULSE
64
INTERVENTIONS FOR SHOCK
RAPID INFUSION IV FLUIDS OR BLOOD ADMIN MEDS TO INCREASE BP AND CONTRACTILITY
65
ORTHOSTATIC HYPOTENSION
a drop in blood pressure that occurs when a client rises to a sitting or standing position.
66
ORTHOSTATIC HYPOTENSION CAN BE CAUSED BY
dehydration, hypotension, heart failure, or a disorder of the central nervous system.
67
S/S OF ORTHOSTATIC HYPOTENSION
FAINTNESS DIZZINESS INCREASED FALL RISK
68
WHAT IS CONSIDERED ORTHOSTATIC HYPOTENSION
DROP IN SYSTOLIC PRESSURE OF AT LEAST 20 OR DIASTOLIC OF AT LEAST 10 WITHING 1 MINUTE
69
TO DETERMINE ORTHOSTATIC HYPOTENSION, YOU SHOULD RECHECK BP AT WHAT TIMES
1 MIN AND 3 MIN
70
INTERVENTIONS TO INCREASE BP
INCREASE FLUIDS IV FLUIDS COMPRESSION STOCKINGS CHANGE POSITIONS SLOWLY SLIGHTLY ELEVATE HOB WHEN SLEEPING AVOID A LYING OR SEATED POSITION OF EXTENDED TIME
71
S/S OF HYPOTENSION
DECREASED CO ACTIVITY INTOLERANCE CHEST PAIN W/ EXERTION
72
PATIENT EDUCATION ON HYPOTENSION
RISK OF DIZZINESS AND FALLING CHANGE POSITIONS SLOWLY AVOID EXTREME TEMPS STAY HYDRATED
73
PRACTICE LABELING HEART IN THE FUNDAMENTALS VS PAGE 2
74
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, B, D, E
75
Name the four stages of hypertension, including the blood pressure values that define each stage.
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
76
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
C
77
WHAT RESULTS IN A FALSELY HIGH BP MSMT
BP CUFF TO LOOSE OBTAINED RIGHT AFTER NICOTICE
78
WHAT WOULD CAUSE FALSELY LOW BP LEVELS
1. LEAVING ARM UNSUPPORTED 2. CUFF IS TOO SMALL 3. CUFF IS TOO LARGE 4. CUFF TOO LOOSE
79
PULSE
RHYTHMIC DILATION OF THE ARTERIES AND PULSATION OF BLOOD FLOW THAT OCCURS WITH EACH CONTRACTION OF THE VENTRICLE
80
SINOATRIAL NODE SA NODE
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
81
BIRTH TO 28 DAYS HR
110-160 BPM
82
1 MONTH TO 1 YEAR HR
90-160 BPM
83
1 YEAR TO 3 YEAR HR
80-140 BPM
84
3 YEAR TO 6 YEAR HR
70-120 BPM
85
6 YEAR TO 12 YEAR HR
60-110 BPM
86
12 YEAR TO 20 YEAR HR
50-100 BPM
87
20 YEAR + HR
60-100 BPM
88
INFLUENCING FACTORS OF HR
BODY POSITION, AGE, ACTIVITY LEVEL, HEALTH CONDITIONS, BODY TEMP, MEDS, UNDERACTIVE THYROID GLAND CAN EVEN CAUSE DECREASE
89
TACHYCARDIA
HR GREATER THAN 100/MIN IN ADULT
90
CAUSES OF TACHYCARDIA
EXERCISE, ANXIETY, CERTAIN MEDS, CAFFEINE, NICOTINE, HEART ABNORMALITIES
91
MANAGING TACHYCARDIA
RELAXATION TECHNIQUES- MEDITATION, YOGA, GUIDED IMAGERY VSLSALVA MANEUVER SMOKING CESSATION
92
VALSALVA MANEUVER
TO ELICIT VASOVAGAL RESPONSE BY STIMULATION OF VAGUS NERVE BEAR DOWN LIKE BM TO STIMULATE THE PARASYMPATHETIC NERVOUS SYSTEM TO DECREASE HR
93
BRADYCARDIA
ADULT HR LESS THAN 60 BPM *EXPECTED IN PHYSICALLY FIT
94
S/S OF BRADYCARDIA
DIZZINESS FATIGUE SHORTNESS OF AIR CHEST PAIN CONFUSION
95
CAUSES OF BRADYCARDIA
CONGENITAL HEART ABNORMALITIES HEART FAILURE HEART MUSCLE DAMAGE HYPOTHYROIDISM
96
MANAGING BRADYCARDIA
CHANGE POSITIONS SLOWLY TAKE MEDS AS PRESCRIBED KEEP ALL APPOINTMENTS
97
ARRHYTHMIA
IRREGULAR RHYTHM OR PULSE RATE
98
S/S OF ARRYTHMIA
*SOME GO UNNOTICED SOB DIZZINESS
99
IF ABNORMAL PULSE, COUNT APICAL FOR HOW LONG
1 MINUTE
100
WHERE TO PALPATE AND AUSCULTATE APICAL PULSE
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
S1
DULL LOW PITCHED LUB USE BELL OF STETHO
102
S2
SHORTER HIGHER PITCHED DUB USE DIAPHRAGM OF STETHO
103
TEMPORAL PULSE
OVER TEMPORAL ARTERY AT TEMPLE
104
BRACHIAL PULSE
OVER BRACHIAL ARTERY USED TO ASSESS QUALITY OF PERFUSION PALPATED IN THE ANTECUBITAL SPACE
105
RADIAL PULSE
RADIAL ARTERY PALPATED OVER THE GROOVE ALONG THE THUMB SIDE OF INNTER WRIST
106
FEMORAL PULSE
OVER FEMORAL ARTERY IN GROIN ON EITHER SIDE OF GENITALS USED TO ASSESS PERFUSION QUALITY
107
POPLITEAL PULSE
POPLITEAL ARTERY LOCATED BEHIND KNEE USED TO ASSESS PERFUSION QUALITY
108
DORSALIS PEDIC PULSE
HEART WITH DOPPLER OR PALPATED OVER DORSALIS PEDIS ARTER LOCATED ON THE DORSAL SIDE OF FOOT ASSESS PERFUSION QUALITY
109
POSTERIOR TIBIAL PULSE
OVER POSTERIOR TIBIAL ARTERY MEDIAL SIDE OF ANKLE ASSESS PERFUSION QUALITY
110
MOST COMMON SITE TO PALPATE PULSE
RADIAL
111
WHEN TO ASSESS PERIPHERAL PULSES
PROCEDURE THAT COULD AFFECT CIRCULATION IMPAIRED PERIPHERAL BLOOD FLOW SUCH AS COOL SKIN TEMP OR SKIN COLOR ALTERATION
112
PULSE DEFICIT
DIFFERENCE BETWEEN APICAL AND PERIPHERAL PULSE IN 1 MINUTE
113
CAUSES OF PULSE DEFICIT
AORTIC RUPTURE CAD ATRIAL FIBRILLATION
114
HOW MANY PEOPLE TO ASSESS PULSE DEFICIT
2 NURSES COUNTING AT THE SAME TIME
115
PULSE RATINGS
0 = ABSENT +1 = WEAK +2 = NORMAL +3 = STRONG +4 = BOUNDING
116
EXPECTED PULSE FINDINGS
OBLITERATED WITH SIGNIFICAN PRESSURE IF STRONG PALPABLE NOT WEAK OR BOUNDING EQUAL BILATERALLY
117
WHAT DO YOU DO WHEN A PERIPHERAL PULSE IS NONPALPABLE
USE DOPPLER ULTRASOUND STETHO TO AUSCULTATE
118
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
B
119
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
D E
120
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
D
121
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
B
122
BODY TEMPERATURE
MEASUREMENT OF BALANCE OF HEAT PRODUCED AND HEAT LOST TO ENVIRONMENT MEASURE IN DEGREES
123
CORE TEMP
TEMP OF THE DEEP TISSUES WITHIN THE BODY
124
SURFACE TEMP
TEMP OF THE SKIN, FAT, SUBQ TISSUE
125
NORMAL BODY TEMP
37 C OR 98.6 F CAN RANGE FROM 37-39 C OR 96.8-100.4 F
126
EXPECTATION OF TEMP IN ELDERLY
SLIGHTLY LOWER
127
WHEN DO WE HAVE OUR LOWEST TEMP
IN THE MORNING.
128
FACTORS OF TEMP
EXERCISE OR STRESS WILL INCREASE COOL ENVIRONMENT WILL DECREASE
129
THERMOREGULATION
BODY'S NATURAL MECHANISM FOR BALANCING BODY TEMP
130
CONDUCTION
LOSS OF HEAT DUE TO DIRECT CONTACT WITH A COOLER SURFACE HOW BODY LOSES HEAT TO ENVIRONMENT
131
CONVECTION
LOSS OF HEAT DUE TO AIR CURRENTS
132
EVAPORATION
LOSS OF HEAT VIA GASES FROM LUNGS OR DRYING OF SWEAT FROM THE SKIN
133
RADIATION
LOSS OF HEAT DUE TO INDIRECT CONTACT WITH OR BEING IN CLOSE PROXIMITY TO A COLER SURFACE
134
WHAT CAUSES A FEVER
UPWARD SHIFT OF BODY'S NATURAL SET POINT IN THE HYPOTHALAMUS GLAND
135
WHAT TEMP IS CONSIDERED A FEVER
38 C 100.4 F
136
S/S OF FEVER
FLUSHED FACE, DIAPHORETIC, SKIN THAT FEELS HOT, EXHIBIT TACHYCARDIA, INCREASED RR
137
FEBRILE
WHAT A PATIENT WITH A FEVER IS CONSIDERED
138
AFEBRILE
WHAT A PATIENT WHOSE FEVER HAS DISSIPATED IS CONSIDERED
139
HYPERTHERMIA
INCREASED TEMP DUE TO INABILITY TO STOP HEAT PRODUCTION OR TO STIMULATE HEAT LOSS
140
WHAT CAUSES HYPERTHERMIA
INABILITY FOR HYPOTHALAMUS TO MAINTAIN REGULATION OF TEMP
141
S/S OF HYPERTHERMIA
DIZZINESS, WEAKNESS, THIRST, NAUSEA
142
IF LEFT UNTREATED, HYPERTHERMIA CAN CAUSE
HYPOTENSION, SYNCOPE, CONFUSION, TACHYCARDIA, IMPAIRED COORDINATION, ORGAN FAILURE, OR DEATH
143
Tx OF HYPERTHERMIA
COOLER ENVIRONMENT REMOVE EXCESS CLOTHING COLD PACKS TO NECK, AXILLAE, AND GROIN FAN IV FLUIDS
144
HYPOTHERMIA
DECREASE IN CORE BODY TEMP DUE TO EXTENDED EXPOSURE TO COLD OR INABILITY TO PRODUCE HEAT
145
S/S OF HYPOTHERMIA
SHIVERING, DECREASED MOTOR SKILLS, IMPAIRED PERIPHERAL PERFUSION, CONFUSION, POOR CONCENTRATION, DILATED PUPILS, LOSS OF CONSCIOUSNESS
146
SEVERE HYPOTHERMIA
MEDICAL EMERGENCY LOSS OF DEEP TENDON REFLEXES COMA HIGH RISK FOR CARDIAC ARREST
147
Tx OF HYPOTHERMIA
WARMING MAT/BLANKET INFANTS IN RADIANT WARMER INCREASE ROOM TEMP ADD LAYER OF CLOTHING HAT/CAP ON HEAD WARMED IV FLUIIDS
148
5 COMMON SITES TO ASSESS BODY TEMP
ORAL, TYMPANIC, TEMPORAL, AXILLARY, RECTAL
149
ORAL TEMP PROS
EASILY ACCESSIBLE ACCURATE TO SURFACE TEMP
150
ORAL TEMP CONS
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
TYMPANIC TEMP PROS
EASILY ACCESSIBLE RAPID RESULT ACCURATE TO CORE TEMP NOT ALTERED BY ENVIRONMENTAL TEMP
152
TYMPANIC TEMP CONS
INACCURATE IF CERUMEN OR EAR INFECTION DIFFICULT TO OBTAIN ACCURATE RESULT IN NEWBONS/INFANTS/CHILDREN YOUNGER THAN 3 REQUIRES HEARING AID REMOVAL
153
TEMPORAL TEMP PROS
EASILY ACCESSIBLE RAPID RESULT NO RISK OF INJURY GOOD FOR ALL AGE GROUPS REFLECTS RAPID CHANGES IN CORE TEMP
154
TEMPORAL TEMP CONS
INACCURATE IF HEAD COVERING CAN BE DISTORTED IF MOISTURE ON SKIN LIKE SWEAT
155
AXILLARY TEMP PROS
GOOD FOR ALL AGE GROUPS NO RISK OF INJURY
156
AXILLARY TEMP CONS
MORE TIME TO READ NOT GOOD FOR RAPID CORE TEMP CHANGES RESULTS ALTERED BY ENVIRONMENT TEMPS
157
RECTAL TEMP PROS
RELIABLE RESULT
158
RECTAL TEMP CONS
RISK OF INJURY TO MUCOSA ALTERED W/ PRESENCE OF STOOL UNPLEASANT FOR CLIENTS DO NOT USE IF DIARRHEA, HEMORRHOIDS, RECTAL SURGERY, COAGULATION DISORDERS
159
TYPES OF THERMOMETERS
ELECTRONIC TYMPANIC TEMPORAL CHEMICAL DOT TEMP SENSITIVE TAPE/PATCH
160
HOW FAR TO INSERT RECTAL THERMOMETER
1/2 INCH TOWARD UMBILICUS DO NOT FORCE
161
What are some nursing interventions you can implement to address his fever?
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
RESPIRATION
THE ACT OF BREATHING
163
2 PHASES OF RESPIRATION
INSPIRATION EXPIRATION
164
INSPIRATION
intake of air by the lungs so as to oxygenate body tissues and support cellular function.
165
WHAT HAPPENS TO THE OXYGEN THAT ENTERS THE LUNGS DURING INSPIRATION
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
MECHANICAL FACTORS OF RESPIRATION
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
The nurse can also assess a client’s respiratory rate and rhythm by
auscultating the client’s lungs with a stethoscope.
168
RESPIRATORY RATE
the number of sets of inspirations and expirations to determine the rate of breaths per minute
169
HOW LONG SHOULD A NURSE OBSERVE RESPIRATIONS
HEALTHY- 30 SECONDS AND MULTIPLY BY 2 ALTERED STATUS- 1 MINUTE
170
EUPNEA
RR WITHIN EXPECTED RANGE
171
BIRTH TO 28 DAYS RR
30-60/MIN
172
1 MONTH - 1 YEAR RR
25-60/MIN
173
1 YEAR - 3 YEARS RR
25-30/MIN
174
3 YRS - 6 YRS RR
20-25 / MIN
175
6 YRS - 12 YRS RR
20-25/MIN
176
12 YRS - 20 YRS RR
16-20/MIN
177
20 YRS + RR
12-20/MIN
178
TACHYPNEA
a respiratory rate that is higher than the expected reference range. A client experiencing tachypnea may also exhibit shallow respirations.
179
S/S OF TACHYPNEA
DIZZINESS TINGLING IN THE HANDS
180
CAUSES OF TACHYPNEA
INCREASED PHYSICAL ACTIVITY PAIN ANXIETY RESPIRATORY INFECTION LIKE PNEUMONIA CHRONIC LUNG DISEASES ASTHMA
181
BRADYPNEA
respiratory rate that is lower than the expected reference range.
182
S/S OF BRADYPNEA
DIZZINESS FATIGUE WEAKNESS CONFUSION IMPAIRED COORDINATION
183
CAUSES OF BRADYPNEA
INCREASED INTRACRANIAL PRESSURE HYPOTHYROIDISM SHOCK ALCOHOL TOXICITY OPIOIDS SEDATIVES MORBID OBESITY
184
APNEA
A CESSATION OF RESPIRATIONS
185
CAUSES OF APNEA
OPIOID TOXICITY TRAUMA NEUROLOGIC DYSFUNCTION
186
CHEYNE-STOKES RESPIRATIONS
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
CAUSES OF CHEYNE STOKES RESPIRATIONS
INCREASED INTRACRANIAL PRESSURE BRAIN TUMOR STROKE HEART FAILURE END OF LIFE
188
KUSSMAUL RESPIRATIONS
REGULAR RHYTHM BUT ABNORMALLY DEEP AND RAPID
189
CAUSES OF KUSSMAUL RESPIRATIONS
SEVERE METABOLIC ACIDOSIS DIABETIC KETOACIDOSIS SEVERE KIDNEY DISEASE
190
QUALITY AKA CHARACTER OF RESPIRATIONS
amount of effort a client must exert to breathe, as well as any audible sounds produced during breathing.
191
RESPIRATORY RETRACTIONS
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
OXYGEN SATURATION SaO2
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
SpO2 s an indication of
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
Prior to measuring a client’s oxygen saturation level, the nurse must choose a site that has
adequate capillary refill. A capillary refill time of less than 2 seconds indicates good perfusion, which can help ensure a reliable result.
195
SITES FOR MEASURING OXYGEN SATURATION
FINGER FOOT, WRIST FOR NEWBORNS EARLOBE ADHESIVE PROBE
196
HOW TO GET ACCURATE SpO2
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
WHAT CAN CAUSE A DECREASE OF SaO2
CHRONIC LUNG DISEASE HYPOTHERMIA DECREASE PERFUSION POOR CARDIAC OUTPUT
198
DYSPNEA
SHORTNESS OF BREATH
199
S/S OF LOW SaO2
DYSPNEA COUGH TACHYCARDIA CONFUSION
200
HYPOXIA
LACK OF OXYGEN TO TISSUES CAN DECREASE MENTAL ALERTNESS AND CONFUSION
201
Tx OF DECREASED SaO2
DEPENDS ON UNDERLYING ETIOLOGY SIT CLIENT UP TAKE DEEP BREATAHS AND COUGH SUPPLEMENTAL 2 MEDICATIONS- BRONCHODILATORS
202
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
B, C, D
203

ATI (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions