Chapter 31

Question 1

afebrile

Answer 1

without a fever

Question 2

blood pressure (BP)

Answer 2

amount of force exerted against artery walls

Question 3

body temperature

Answer 3

amount of heat in body; balanced between heat produced and amount lost

Question 4

bradycardia

Answer 4

slow heart rate; less than 60bpm

Question 5

diastolic pressure

Answer 5

pressure in arteries when hearts at rest

Question 6

febrile

Answer 6

with fever

Question 7

fever

Answer 7

elevated body temperature; over 100°

Question 8

hypertension

Answer 8

high BP

Question 9

hypotension

Answer 9

low BP

Question 10

pulse

Answer 10

beat of heart felt as blood passes through artery

Question 11

pulse rate

Answer 11

number of heartbeats per min (BPM)

Question 12

respiration

Answer 12

inhaling and exhaling

Question 13

stethoscope

Answer 13

instrument used to listen to sounds produced by heart, lungs, etc.

Question 14

systolic pressure

Answer 14

pressure in arteries when heart contracts

Question 15

tachycardia

Answer 15

fast heart rate; more than 100bpm

Question 16

thermometer

Answer 16

deice used to measure temperature

Question 17

vital signs

Answer 17

temp, pulse, respiration, BP (pulse oximeter / pain in SOME agencies)

Question 18

TPR

Answer 18

temperature, pulse, respiration

Question 19

report vital signs to nurse when ?

Answer 19

• changes from prior measurement
• abnormal vital signs; out of normal range

Question 20

how to take vital signs from person with dementia ?

Answer 20

2 staff; one to take vitals, other to distract

Question 21

temperature sites

Answer 21

• oral
• tympanic (ear)
• axillary (armpit)
• temporal
• rectal

Question 22

temperature sites for persons who are confused / resist care ?

Answer 22

tympanic / temporal

Question 23

rectal sites are dangerous for what kind of persons ?

Answer 23

those with heart disease; thermometer stimulates the vagus nerve, slowing heart to low levels

Question 24

least reliable temperature site ?

Answer 24

axillary

Question 25

baseline oral temp

Answer 25

98.6°F

Question 26

baseline rectal temp

Answer 26

99.6°F

Question 27

baseline axillary temp

Answer 27

97.6°F

Question 28

baseline tympanic temp

Answer 28

98.6°F

Question 29

baseline temporal temp

Answer 29

99.6°F

Question 30

nurse and care plan tell you what about taking a persons temp ?

Answer 30

- when to take temp - what site to use - what thermometer to use

Question 31

proper use of a glass thermometer

Answer 31

- hold by stem - shake down by snapping thermometer down, until mercury line is below lowest number - after use, read at eye level

Question 32

properly taking rectal temp

Answer 32

- side-lying person - lift up upper butt-cheek - insert thermometer 1/2in

Question 33

pulse sites (9)

Answer 33

- apical (2-3in left of heart) - temporal - carotid (neck) - brachial - radial - femoral - popliteal (back knee) - posterior tibial (ankle) - pedal (top foot)

Question 34

apical pulse taken when person has ?

Answer 34

- heart disease - irregular heart rhythms - taking drugs affecting the heart

Question 35

count respiration when ?

Answer 35

do NOT tell person; will change respiration rate - after taking pulse - person is at rest

Question 36

regular respiration measurements ?

Answer 36

- 12-20 respirations per min - quiet, effortless, regular on both sides

Question 37

systole

Answer 37

heart contraction

Question 38

diastole

Answer 38

heart rest

Question 39

normal BP

Answer 39

90-120 / 60-80 mm HG (systolic / diastolic) report anything outside this range

Question 40

what arms do you not take BP on ?

Answer 40

- IVs - cast - dialysis access site - side of breast surgery - injured

Question 41

how to take BP ?

Answer 41

- let person rest 10-20 min before - person sitting / lying down - arm at heart position, resting - hands up

Question 42

what do you do if unable to take BP ?

Answer 42

wait 30-60 sec; if not, ask nurse

Question 43

pulse oximetry

Answer 43

blood oxygen level; taken with other vitals

Question 44

pain

Answer 44

warning sign from the body; signals tissue damage

Question 45

measuring weight / height

Answer 45

- measured upon admission - measured daily (daily, weekly, monthly, depends) - in sleepwear / gown only - voided (after going to bathroom) - at same time of day before eating - same scale