Chapter 11 Vital Signs

Question 1

Apical pulse

Answer 1

Heartbeat as measured with the bell or disk of stethoscope placed over the apex of the heart; represents the actual beating of the heart. Most authentic of all pulses.

Question 2

Auscultate/auscultation

Answer 2

To listen for sounds within the body to evaluate the condition of the heart, lungs, pleura, intestines, or other organs or to detect fetal heart sounds.

Question 3

Blood pressure

Answer 3

Pressure exerted by the circulation volume of blood on the arterial walls, veins, and chambers of the heart.

Question 4

Bradycardia

Answer 4

Slow rhythm characterized by a pulse rate of fewer than 60 beats per minute.

Question 5

Bradypnea

Answer 5

A slow respiratory rate of fewer than 12 breaths per minute.

Question 6

Cheyne-Stokes respiration

Answer 6

An abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing.

Question 7

Diastolic pressure

Answer 7

The second number recorded in the blood pressure reading; represents the minimum level of blood pressure measured between the contractions of the heart.

Question 8

Dyspnea

Answer 8

Shortness of breath or difficulty in breathing; may be caused by disturbances in the lungs, certain heart conditions, and hemoglobin deficiency.

Question 9

Dysrhythmia

Answer 9

Any disturbance or abnormality in a normal rhythmic pattern, specifically irregularity in the normal rhythm of the heart.
AKA: arrhythmia

Question 10

Febrile

Answer 10

Body temperature above normal.

Question 11

Hypertension

Answer 11

Occurs when the elevated blood pressure is above normal.

Question 12

Hyperthermia

Answer 12

Condition of abnormally high body temperature.

Question 13

Hypotension

Answer 13

Occurs when the blood pressure is below normal.

Question 14

Hypothermia

Answer 14

Condition of abnormally low body temperature.

Question 15

Korotkoff sounds

Answer 15

Sounds heard while measuring blood pressure when using a sphygmomanometer and stethoscope.

Question 16

Orthostatic hypotension

Answer 16

A drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when moving from a lying to sitting position.

Question 17

Pulse

Answer 17

A rhythmic beating or vibrating movement; regular recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts.

Question 18

Pulse deficit

Answer 18

A condition that exists when the radial pulse rate is less than the ventricular rate as auscultated at the apex of the heart.

Question 19

Pulse pressure

Answer 19

Difference between the systolic and diastolic blood pressures, usually 30 to 40 mm Hg.

Question 20

Respiration

Answer 20

The taking in of oxygen, its use in the tissues, and the icing off of carbon dioxide; the act of breathing. (Inhaling and exhaling)

Question 21

Sphygmomanometer

Answer 21

Device for measuring arterial blood pressure.

Question 22

Stethoscope

Answer 22

Instrument placed against patient’s body to hear heart, lung, or bowel sounds.

Question 23

Systolic

Answer 23

the number or reading that represents ventricles contracting, forcing blood into the aorta and pulmonary arteries. In blood pressure readings, it is the higher of the two readings.

Question 24

Tachycardia

Answer 24

An abnormal condition in she has the myocardium contracts regularly but at a rate greater than 100 beats per minute.

Question 25

Tachypnea

Answer 25

An abnormally rapid rate of breathing.

Question 26

Temperature

Answer 26

Relative measure of sensible heart or cold.

Question 27

Tympanic

Answer 27

Membranous eardrum.

Question 28

Vital signs

Answer 28

Measurement of temperature, pulse, respiration, and blood pressure. Some places use pain as a fifth vital sign.

Question 29

When to assess vitals

Answer 29

During admission and discharge, on a routine schedule as determined by healthcare provider’s order, before and after surgical procedures, before and after invasive diagnostic procedures, before and after administering certain medications especially those that affect cardiovascular, Respiratory, and temperature control function. When it patient’s general condition changes. Before and after certain nursing interventions. When the patient report nonspecific symptoms of physical distress. Routinely is part of the procedure such as a blood transfusion or liver biopsy. When assessing patient during a home health care visit. Pain must be evaluated in documented each time other vital signs were taken.

Question 30

Neonate vitals

Answer 30

120-160 heart rare, 36-60 respiration, systolic 20-60 B/P

Question 31

Infant vitals

Answer 31

125-135 heart rate, 40-46 respiration, systolic 70-80 B/P

Question 32

Toddler vitals

Answer 32

90-120 heart rare, 20-30 respiration, systolic 80/100

Question 33

School aged vitals (6-10)

Answer 33

65-105 heart rate, 22-24 respiration, systolic 90-100, diastolic 60-64

Question 34

Adolescent 10-18

Answer 34

65-100 heart rate, 16-22 respiration, systolic 100-120, diastolic 70-80 B/P

Question 35

Adult

Answer 35

60-100 heart rate, 12-20 respiration, systolic 100-120, diastolic 70-80 B/P

Question 36

Older adult

Answer 36

60-100 heart rate, 12-18 respiration, systolic 130-140, diastolic 90-95 B/P

Question 37

Beta blockers

Answer 37

Reduces B/P

Question 38

Steroids

Answer 38

Reduces temp

Question 39

Absent pulse

Answer 39

None felt

Question 40

Thready pulse

Answer 40

+1 difficult to feel, not palpable when only slight pressure applied.

Question 41

Weak pulse

Answer 41

+2 somewhat stronger than a thready pulse but not palpable when light pressure applied.

Question 42

Normal pulse

Answer 42

+3 easily felt but not palpable when moderate pressure applied.

Question 43

Bounding pulse

Answer 43

+4 feels full and spring like even under moderate pressure