Ch 30: Vital Signs - SG PT2

Question 1

Define Tachycardia

Answer 1

Tachycardia is an abnormal elevated heart rate

(>100 beats/min in adults)

Question 2

Define Bradycardia

Answer 2

Bradycardia is a slow rate

(<60 beats/min in adults)

Question 3

Define Pulse Deficit

Answer 3

Pulse deficit is an inefficient contraction of the heart
that fails to transmit a pulse wave to the peripheral site; it is the difference between the apical and the radial pulse rate.

Question 4

Define Dysrhythmia

Answer 4

A dysrhythmia is an abnormal rhythm, including early, late, or missed beats.

Question 5

Define Respiratory Ventilation

Answer 5

Ventilation is the movement of gases in and out of the lungs.

Question 6

Define Respiratory Diffusion

Answer 6

Diffusion is the movement of oxygen and carbon dioxide between the alveoli and the red blood cells.

Question 7

Define Respiratory Perfusion

Answer 7

Perfusion is the distribution of red blood cells to and from the pulmonary capillaries.

Question 8

Define Hypoxemia

Answer 8

Hypoxemia is low levels of arterial O₂

Question 9

Identify which phase of respirations is active and which is passive.

• Inspiration
• Expiration

Answer 9

• Inspiration = Active
• Expiration = Passive

Question 10

Identify factors that influence the character of respirations and the mechanism of each factor

Answer 10

• Exercise: increases rate and depth
• Acute Pain: alters rate and rhythm of respirations; breathing becomes shallow.
• Anxiety: increases respiration rate and depth as a result of sympathetic stimulation
• Smoking: changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking

Question 11

What is the acceptable respiratory rate for adults?

Answer 11

12-20

Question 12

Briefly explain the alterations in breathing patterns for:

Bradypnea

Answer 12

Rate of breathing is regular but slow; <12 breaths/ min.

Question 13

Briefly explain the alterations in breathing patterns for:

Tachypnea

Answer 13

Rate of breathing is regular but rapid; >20 breaths/ min.

Question 14

Briefly explain the alterations in breathing patterns for:

Hyperpnea

Answer 14

Respirations are labored and increased in depth, and the rate is >20 breaths/min.

Question 15

Briefly explain the alterations in breathing patterns for:

Apnea

Answer 15

Respirations cease for several seconds.

Question 16

Briefly explain the alterations in breathing patterns for:

Hyperventilation

Answer 16

Rate and depth of respirations increase

Question 17

Briefly explain the alterations in breathing patterns for:

Hypoventilation

Answer 17

Respiratory rate is abnormally low, and depth of ventilation is depressed

Question 18

Briefly explain the alterations in breathing patterns for:

Cheyne–Stokes:

Answer 18

Respiratory rate and depth are irregular; alternating periods of apnea and hyperventilation

Question 19

Briefly explain the alterations in breathing patterns for:

Kussmaul

Answer 19

Kussmaul respirations are abnormally deep, regular, and increased in rate

Question 20

Briefly explain the alterations in breathing patterns for:

Biot

Answer 20

Biot respirations are abnormally shallow for two or three breaths followed by an irregular period of apnea

Question 21

Briefly explain the alterations in breathing patterns for:

SaO₂

Answer 21

SaO₂ is the percentage of hemoglobin that is bound with oxygen in the arteries and is the percent of saturation of hemoglobin; normal range is usually
between 95% and 100%

Question 22

Define Blood Pressure

Answer 22

Blood pressure is the force exerted on the walls of an artery by the pulsing blood under pressure from the heart.

Question 23

Define Systolic Pressure

Answer 23

Systolic pressure is the peak of maximum pressure
when ejection occurs

Question 24

Define Diastolic Pressure

Answer 24

Diastolic pressure occurs when the ventricles relax; the blood remaining in the arteries exerts a minimum pressure

Question 25

Define Pulse Pressure

Answer 25

Pulse pressure is the difference between systolic and diastolic pressure

Question 26

How is blood pressure effected by cadiac output?

Answer 26

Cardiac output increases as a result of an increase in heart rate, greater heart muscle contractility, or an increase in blood volume; thus raising blood pressure

Question 27

How does peripheral resistance relate to blood pressure?

Answer 27

Peripheral resistance is the resistance to blood flow determined by the tone of vascular musculature and diameter of blood vessels.

Question 28

How does blood volume affect blood pressure?

Answer 28

The volume of blood circulating within the vascular system affects blood pressure, which normally remains constant. Higher blood volume = higher BP

Question 29

How does blood viscosity affect blood pressure?

Answer 29

Viscosity is the thickness that affects the ease with which blood flows through blood vessels, determined by the hematocrit.

Thicker = higher bp, thinner = lower

Question 30

How does blood vessel elasticity affect blood pressure?

Answer 30

With reduced elasticity, there is greater resistance to blood flow, and the systemic pressure rises (systolic pressure).

Question 31

List eight factors that influence blood pressure.

Answer 31

1. Age
2. Stress
3. Ethnicity
4. Gender
5. Daily variations
6. Medications
7. Activity and weight
8. Smoking

Question 32

Optimal blood pressure in adults is…

Answer 32

<120 / <80

Question 33

List some of the risk factors that are linked to hypertension

Answer 33

• Family history,
• obesity,
• smoking,
• heavy alcohol consumption,
• high sodium,
• sedentary life- style,
• continuous stress,
• diabetics,
• older, African Americans

Question 34

Identify some of the risk factors for orthostatic hypotension

Answer 34

• Dehydrated,
• anemic,
• experienced
• prolonged bed rest,
• recent blood loss,
• medications

Question 35

Define Orthostatic Hypotension

Answer 35

A decrease in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within three minutes of standing when compared with blood pressure from the sitting or supine position.

Question 36

Identify the first through fifth Korotkoff sounds.

Answer 36

• First: Clear, rhythmic tapping corresponding to the pulse rate that gradually increases in intensity (systolic pressure)
• Second: Blowing or swishing sound as the cuff deflates
• Third: A crisper and more intense tapping
• Fourth: Muffled and low-pitched as the cuff is further deflated (diastolic pressure in infants and children)
• Fifth: The disappearance of sound (diastolic pressure in adolescents and adults)

Question 37

Identify at least two variations in temperature that are unique to older adults.

Answer 37

• The temperature of older adults is at the lower end of the normal temperature range, (96.8° to 98.3° F). Therefore temperatures considered within normal range sometimes reflect a fever in an older adult.
• Older adults are very sensitive to slight changes in environmental temperature because their thermoregulatory systems are not as efficient.
• A decrease in sweat gland reactivity in the older adult results in a higher threshold for sweating at high temperatures, which leads to hyperthermia and heatstroke.
• Be especially attentive to subtle temperature changes and other manifestations of fever in this population such as tachypnea, anorexia, falls, delirium, and overall functional decline.

• Older adults without teeth or with poor muscle control may be unable to close their mouths tightly to obtain accurate oral temperature readings.

Question 38

Identify at least two variations in pulse that are unique to older adults.

Answer 38

• Pedal pulses are often difficult to palpate in older adults.
• The older adult has a decreased heart rate at rest.
• It takes longer for the heart rate to rise in the older adult to meet sudden increased demands that result from stress, illness, or excitement. Once elevated, the pulse rate takes longer to return to normal resting rate.
• Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs.

Question 39

Identify at least two variations in blood pressure that are unique to older adults.

Answer 39

• Older adults who have lost upper arm mass, require special attention to selection of a smaller size blood pressure cuff.
• Older adults sometimes have an increase in systolic pressure related to decreased vessel elasticity, whereas the diastolic pressure remains the same, resulting in a wider pulse pressure.
• Instruct older adults to change position slowly and wait after each change to avoid postural hypotension and prevent injuries.
• Skin of older adults is more fragile and susceptible to cuff pressure during frequent measurements. More frequent assessment of skin under the cuff or rotating blood pressure sites is recommended.

Question 40

Identify at least two variations in respirations that are unique to older adults.

Answer 40

• Aging causes ossification of costal cartilage and downward slant of ribs, resulting in a more rigid rib cage, which reduces chest wall expansion. Kyphosis and scoliosis that occur in older adults also restrict chest expansion and decrease tidal volume.
• Older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles.
• The respiratory system matures by the time a person reaches 20 years of age and begins to decline in healthy people after the age of 25. Despite this decline older adults are able to breathe effortlessly as long as they are healthy. However, sudden events that require an increased demand for oxygen create shortness of breath in the older adult.
• Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia.

Question 41

The skin plays a role in temperature regulation by:

1. Insulating the body
2. Constricting blood vessels
3. Sensing external temperature variations
4. All of the above

Answer 41

4. The skin regulates the temperature through insula-
   tion of the body, vasoconstriction, and temperature
   sensation

Question 42

The nurse bathes the patient who has a fever with cool water. The nurse does this to increase heat loss by means of:

1. Radiation
2. Convection
3. Conduction
4. Condensation

Answer 42

3. The transfer of heat from one object to another
   with direct contact (solids, liquids, and gases

Question 43

The nurse is assessing a patient who she suspects has the nursing diagnosis hyperthermia related to vigorous exercise in hot weather. In reviewing the data, the nurse knows that the most important sign of heatstroke is:

1. Confusion
2. Excess thirst
3. Hot, dry skin
4. Muscle cramps

Answer 43

3. Victims of heat stroke do not sweat

Question 44

The nurse is auscultating Mrs. McKinnon’s blood pressure. The nurse inflates the cuff to 180 mm Hg. At 156mmHg, the nurse hears the onset of a tapping sound. At 130mmHg, the sound changes to a murmur or swishing. At 100mmHg, the sound momentarily becomes sharper, and at 92mmHg, it becomes muffled. At 88mmHg, the sound disappears. Mrs. McKinnon’s blood pressure is:

1. 130/88mmHg
2. 156/88mmHg
3. 180/92mmHg
4. 180/130mmHg

Answer 44

2. 156 is the onset of the first Korotkoff sound (sys-
   tolic pressure), and 88 is the fifth sound that corre- sponds with the diastolic pressure.