Ch. 10 (Vital Signs) Flashcards
What are objective measurements of the body’s essential functions called?
vital signs
What are the five objective measurements we gather when assessing a patient’s vital signs?
- temperature
- pulse
- respiratory rate
- blood pressure
- oxygen saturation
During a vital sign assessment, the nurse is assessing which cognitive function when they ask the patient about the date and time?
orientation
What kind of disorders are disorders of decreased mental function resulting from a medical or physical disease, rather than a psychiatric illness?
organic disorder
When assessing a patient’s vital signs, we use multiple different tests.
What kind of test is used to screen whether a patient has cognitive impairment, usually using a three-word recall method?
Mini-Cog test
How many words would the nurse ask the patient to recall when using the Mini-Cog instrument to test the cognitive ability of a patient?
three
Which cognitive function is the nurse assessing during a mental status assessment, when the nurse asks about the patient’s first job?
remote memory
During a vital sign’s assessment..
What shows the strength of the heart’s stroke volume?
the force of the pulse
During a vital sign’s assessment..
What kind of pulse denotes an increased stroke volume?
full, bounding pulse
During a vital sign’s assessment..
What kind of scale is used when recording the pulse force of a patient?
three-point scale
(some agencies use a four-point scale)
During a vital sign’s assessment..
What force on the three-point pulse force scale would most healthy adults fall under?
2+
During a vital sign’s assessment..
What kind of pulse reflects a decreased stroke volume?
weak, thready pulse
On a three-point pulse force scale…
What would a pulse force of 3+ mean?
full, bounding (increased stroke volume: anxiety, exercise, some abnormal conditions)
On a three-point pulse force scale…
What would a pulse force of 2+ mean?
normal
On a three-point pulse force scale…
What would a pulse force of 1+ mean?
weak, thready (decreased stroke volume: hemorrhagic stock)
On a three-point pulse force scale…
What would a pulse force of 0 mean?
absent
What is the normal resting beats per minute range in 95% of healthy individuals?
50-95 beats/min
rate varies with age (more rapid the younger you are)
What is an indication of orthostatic hypotension?
dizziness with position changes
What can prevent accurate readings for pulse oximetry during a vital signs assessment?
dark nail polish
What consistent blood pressure readings average would indicate hypertension?
160/90 mm Hg
During a vital signs assessment, what would define a drop in blood pressure that occurs with change in position?
orthostatic hypotension
What vital sign would the nurse assess first in a patient who reports occasional dizziness and light-headedness upon standing?
blood pressure
What vital sign would the nurse assess first in a patient who reports signs of a fever, such as chills?
temperature
What vital sign would the nurse assess first in a patient who reports difficulty breathing?
respiratory rate and oxygen saturation levels
What refers to a drop in systolic pressure of >20 mm Hg or diastolic pressure >10 mm Hg after changing to a standing position?
orthostatic hypotension
What vital sign would the nurse assess first when suspecting the patient to have a volume depletion?
blood pressure and pulse
What vital sign would the nurse assess first in a patient who reports da history of hypertension?
blood pressure and pulse
What is the average healthy adult respiratory rate and range?
20 breaths/minute with a range of 16-25 breaths/minute
During a vital sign’s assessment..
If the nurses notices a patient’s heart rate is irregular, how long should the pulse be counted for?
a full minute (60 seconds)
During a vital sign’s assessment..
If the nurse notices a patient’s heart rate is regular, how long should the pulse be counted for?
30 seconds and multiply by 2
During a vital sign’s assessment..
What is the most acurrate way to measure temperature route in a patient?
rectal temperature
During a vital sign’s assessment..
What is the most accurate way to measure temperature route in a patient who is unresponsive?
rectal temperature
What is the normal average oral temperature of an adult?
98.6 F
What is the normal arterial oxygen saturation (SpO2) for a healthy person with no lung disease?
97-99%
value >95 is clinically acceptable in presence of normal hemoglobin
At what age would a nurse begin routine monitoring of blood pressure in children at low risk for hypertension?
3 years old
During a vital sign’s assessment..
Besides being ill, what would alter the temperature of the oral cavity, skewing readings on an oral thermometer?
the intake of hot or cold liquid
When is temperature lowest in the day?
first thing in the morning/when patient wakes up
When is temperature highest in the day?
midday
What kind of routes can a nurse take when assessing temperature?
- oral
- temporal
- tympanic
- axiliary
- rectal
What is the most convenient measure of temperature route in a patient?
oral
What is 98.6 F in celcisus?
37 C
If an adult patient comes in with a heart rate over 100, what state would that be referred to as?
tachycardia
If an adult patient comes in with a heart rate under 60, what state would that be referred to as?
brachycardia
If an adult patient comes in with a pulse force that is weak, three-point pulse force scale, where would this patient fall?
1+
If an adult patient comes in with a pulse force that is high, three-point pulse force scale, where would this patient fall?
3+
If an adult patient comes in with a respiration rate above 25 breaths/minute, what state would that be referred to as?
tachypnea
If an adult patient comes in with a respiration rate within the range of 8 to 12 breaths/minute, what state would that be referred to as?
bradypnea
What is the normal respiratory rate range for a healthy adult?
12-18 breaths/minute
What is defined as the force of the blood pushing against the side of the vessel wall?
blood pressure
What are five different internal cardiac factors that influence blood pressure?
- cardiac output
- peripheral vascular resistance (opposition to blood flow through the arteries)
- volume of circulating blood
- viscosity (“thickness”)
- elasticity of vessel walls
What is classified as the maximum pressure felt on the artery during left ventricular contraction?
systolic
What is classified as the elastic recoil, or resting, pressure that the blood exerts constatnly between each contraction?
diastolic
What is the difference between the systolic and diastolic pressures and reflects the stroke volume?
pulse pressure
What are the different general factors that influence blood pressure?
- age (gradual rises)
- sex (female:higher after puberty)
- race (non-hispanics:higher risk of hypertension)
- social determinants (environmental/social factors)
- diurnal rhythm (high: late affertnoon
When taking blood pressure with a stethoscope, when you no longer hear the blood flowing after releasing the air from the diaphragm, what does that mean?
represents the diastolic blood pressure
When taking blood pressure with a stethoscope, when you start hearing a beat, what does that mean?
represents the systolic blood pressure
How do you take blood pressure accurately?
- arm heart level
- right-size cuff
- legs must both be on the ground
- no talking
- bladder must be empty
- exercising and intake of coffee should be done 30 minutes before
- clothes should be removed from area/pushed up
What usually results in an inaccurate blood pressure reading?
the wrong size cuff
An adult patient comes in with a blood pressure with a systolic number less than 120 and diastolic number less than 80, what blood pressure category would they fall under?
normal
An adult patient comes in with a blood pressure with a systolic number in the range of 120-129 and a diastolic number less than 80, what blood pressure category would they fall under?
elevated
An adult patient comes in with a blood pressure with a systolic number in the range of 130-139 and a diastolic number in the range of 80-89, what blood pressure category would they fall under?
high blood pressure (hypertension) stage 1
A patient comes in with COPD or some sort of respiratory disease, what would be a normal oxygen saturation level for them?
90% and above
Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client’s temperature is 36.1C (97 F). The client’s remaining vital signs are in the normally acceptable range. What should the nurse do next?
check the client’s temperature history
An adult patient comes in with a blood pressure with a systolic number 140 or higher and a diastolic number 90 or higher, what blood pressure category would they fall under?
high blood pressure (hypertension) stage 2
An adult patient comes in with a blood pressure with a systolic number higher than 180 and a diastolic number higher than 120, what blood pressure category would they fall under?
hypertensive crisis (consult your doctor immediately)
What happens when the heart contracts inefficiently and does not transmit a pulse wave to a peripheral site?
pulse deficit
What is commonly associated with pulse deficits?
irregular cardiac rhythms and alterations in cardiac output
What is often considered the fifth vital sign?
pain
Each pulsation you hear is a combination of two sounds. What are those two sounds?
S1 and S2
Each pulsation you hear is a combination of two sounds. What is the sound you hear when the tricuspid and mitral valves close at the end of the ventricular filling and just before systolic contraction begins?
S1
Each pulsation you hear is a combination of two sounds. What is the sound you hear when the pulmonic and aortic valves/semilunar valves close at the end of systolic contraction?
S2
When determining the apical pulse, where do you place the bell or diaphragm of your stethoscope?
at the point of maximal impulse (PMI) or apical impulse 8
Out of all the Korotkoff sounds, which one is the loudest?
third sound, phase during which blood flows freely through an increasingly open artery. As a result, the sounds are crisper and more intense.
Out of all the Korotkoff sounds, which one corresponds with the client’s systolic blood pressure?
the first sound, rhymatic tapping sound
A nurse is collecting data about a client’s respiratory condition. What following action should the nurse take to determine the depth of the client’s respiration?
observe the degree of chest-wall movement during inspiration and expiration
What is the expected range of respiration rate per minute in an adult?
12-20/min
During a fever, which vital signs are expected to be increased besides temperature?
elevated pulse rate (increase in metabolic rate & peripheral vasodilation)
When measuring a client’s temperature orally, where should the probe be placed?
in the posterior lingual pocket lateral to the midline
When taking an adult’s client’s temperature rectally, how deep should you insert the probe?
2.5 cm (1in) into the client’s anus
When ausculatating a client’s apical pulse, where can you find the point of maximal impulse (PMI)?
- locate angle of Louis
- slide fingers down each side to locate second intercostal space
- gently move fingers down left side of sternum to fifth intercostal space and laterally to the left midclavicular line
What position should a client be placed in when assessing respiration?
in a bed with their head elevated 45-60 degrees
Convert 40 degrees celsius to fahrenheit?
104
Convert 39 degrees celsius to fahrenheit?
102
Convert 38 degrees celsius to fahrenheit?
100
Convert 37 degrees celsius to fahrenheit?
98
