Ch. 29 Vital Signs

Question 1

6 types vital signs

Answer 1

Temperature 
Pulse
Respirations
Blood pressure
Oxygen saturation 
Pain

Question 2

Vital signs monitor what?

Answer 2

functions taking place in the body

Question 3

What gives the healthcare provider the baseline data of a clients healthcare status?

Answer 3

Vital signs

Question 4

Vital signs measure the effectiveness of what body functions?

Answer 4

Circulatory
Respiratory
Neural
Endocrine

Question 5

T/F

Vital signs are a nursing intervention

Answer 5

True

Question 6

T/F

Vital signs cannot be done without a physicians order

Answer 6

False

Question 7

Shivering does what?

Answer 7

Increases heat production

Question 8

Sweating is also known as

Answer 8

Diaphoresis

Question 9

Sweating is inhibited to do what?

Answer 9

Decrease heat loss

Question 10

Vasoconstriction does what?

Answer 10

Decreases heat loss

Question 11

Vasoconstriction

Answer 11

Narrowing of the blood vessels resulting from contraction of the muscular walls of the vessels

Question 12

WAYS HEAT LEAVES THE BODY

Radiation

Answer 12

Transfer of heat from surface of one object to another without contact

Ex. Infrared rays

Question 13

WAYS HEAT LEAVES THE BODY

Conduction

Answer 13

Applying an ice pack to decrease edema

Question 14

WAYS HEAT LEAVES THE BODY

Convection

Answer 14

A fan blowing air on patient who is perspiring

Question 15

WAYS HEAT LEAVES THE BODY

Evaporation

Answer 15

Perspiration

Question 16

WAYS HEAT LEAVES THE BODY

Insensible water loss

Answer 16

Breathing

Question 17

Have an immature thermoregulatory system, influenced by environment

Answer 17

Infants

Question 18

At risk for hypothermia (loss of subcutaneous fat; reduced thermoregulatory efficiency)

Answer 18

Elderly

Question 19

Circadian rhythm

Answer 19

Temp varies throughout the day, temp is highest at about 6pm; lowest at 1am-4am

Question 20

TF

hormones can increase temp

Answer 20

True

Ex. Estrogen

Question 21

TF

Stress can increase temp

Answer 21

True

Question 22

TF

Disease or trauma to the hypothalamus can effect body temp

Answer 22

True

Question 23

Pyrexia

Answer 23

Fever

100.4+

Question 24

Hyperrexia

Answer 24

Very high temp

Above 105.8F

Question 25

Febrile

Answer 25

Fever | 100.4+

Question 26

Afebrile

Answer 26

No fever

Question 27

Intermittent (fever)

Answer 27

Temp alternates between periods of fever and normal/subnormal temp

Question 28

Remittent (fever)

Answer 28

Wide range of temp fluctuation | Ex. Cold or flu

Question 29

Relapsing (fever)

Answer 29

Short febrile periods with 1 or 2 days of normal temp

Question 30

Sustained (fever)

Answer 30

Temp remains constant

Question 31

Fever spikes

Answer 31

Temp rises to fever level rapidly and then returns to normal within a few hours Eg. bacterial blood infections

Question 32

8 Clinical manifestations of fever

Answer 32

``` Shivering Lethargy Convulsions Pale, cold skin Goose bump look to flesh Flushed face Increased heart rate Increased respiratory rate ```

Question 33

Hypothermia

Answer 33

Core body temp below 95F

Question 34

Causes of hypothermia

Answer 34

Immersion in water Lack of heat to body Lack of appropriate cover/shelter Impaired hypothalamic thermoregulation

Question 35

Frostbite

Answer 35

Skin and underlying tissues are damaged by freezing cold Usually hands, feet, nose, ears

Question 36

temp check in Sublingual area under the tongue

Answer 36

Oral

Question 37

Temp taken in the ear

Answer 37

Tympanic

Question 38

Temp taken in anal canal

Answer 38

Rectal

Question 39

Temp taken in armpit

Answer 39

Auxiliary

Question 40

Temp taken on forehead

Answer 40

Skin/temporal/artery

Question 41

How far do you insert probe when taking rectal temp in adult?

Answer 41

1 1/2”

Question 42

Tympanic temp reading in child ages 3+

Answer 42

Pull pinna up and back

Question 43

Tympanic temp reading in child under 3 y.o.

Answer 43

Pull pinna down and back

Question 44

Pulse

Answer 44

Palpable blinding of blood flow in a peripheral artery; indicator of circulatory status

Question 45

Peripheral pulses

Answer 45

Located away from the heart

Question 46

Apical pulse

Answer 46

At apex of heart; use stethoscope. Pulse recorded as BPM

Question 47

Carotid pulse site

Answer 47

Neck

Question 48

Brachial pulse site

Answer 48

Forearm

Question 49

Radial pulse side

Answer 49

Wrist (lateral)

Question 50

Ulnar pulse site

Answer 50

Wrist (medial)

Question 51

Femoral pulse site

Answer 51

groin

Question 52

Popliteal pulse site

Answer 52

Back of knee

Question 53

Posterior tibial pulse site

Answer 53

Ankle

Question 54

Dorsalis pedis pulse site

Answer 54

Foot

Question 55

What is the normal respiration range

Answer 55

12-20 per minute

Question 56

Perfect blood pressure reading

Answer 56

120/80

Question 57

Top number in blood pressure reading

Answer 57

Systolic

Question 58

Bottom number in blood pressure reading

Answer 58

Diastolic

Question 59

What is the normal pulse range?

Answer 59

60-100 BPM