CHAPTER 4 GEN INSPECTION/MEASUREMENT OF VITAL SIGNS

Question 1

When does general inspection begin?

Answer 1

the moment nurse meets patient

Question 2

True or false? Assessing presence of pain is considered standard
baseline data collected for all patients and
included with assessment of vital signs.

Answer 2

true

Question 3

body temp is regulated by the ___

Answer 3

hypothalamus

Question 4

how does the body generate heat?

Answer 4

heat is gained through the processes of metabolism and exercise

Question 5

how is heat lost?

Answer 5

radiation, convection, evaporation, conduction

Question 6

What are expected temperature ranges in celsius?

Answer 6

35.8-37.3

Question 7

True or false? 35.8-37.3 C is the body temperature at which cellular metabolism is most efficient

Answer 7

true

Question 8

True or false? emperature during menstrual cycle increases
from 0.5° F to 1.0° F (0.3° C to 0.6° C) at
ovulation and remains elevated until menses
cease because of progesterone secretion

Answer 8

true

Question 9

Diurnal variations of _ F to _ F occur, with the
lowest temperature in the _____ and highest in the
late _____.

Answer 9

1, 1.5, morning, afternoon

Question 10

a patient has just ingested hot or cold liquids or was smoking. how long should we wait to take their temperature orally?

Answer 10

10 minutes

Question 11

how is oral temperature taken?

Answer 11

Electronic thermometer (sheathed): under
tongue in sublingual pocket for 15 to 30
seconds

Question 12

true or false? the sublingual pocket receives blood supply from carotid artery, indirectly reflecting core temperature.

Answer 12

true.

Question 13

in which populations are oral temps most often taken?

Answer 13

school-aged children, confused adults

Question 14

how are tympanic temperatures taken?

Answer 14

Probe covered with protective sheath, placed in
external ear canal in contact with all sides of canal
for 2 to 3 seconds

Question 15

true or false? axillary temperature measurement is very accurate.

Answer 15

false. axiallary temperatures have questionable accuracy.

Question 16

heart rate vs rhythm

Answer 16

heart rate = number of times per minute a pulsation is felt
rhythm = regularity of pulsations

Question 17

If pulse rhythm is irregular, note any odd rhythm, and
count pulsations for how long?

Answer 17

a full minute. basically do it again

Question 18

Radial artery is most frequently used to measure
heart rate because

Answer 18

accessible and easily
palpated

Question 19

where is the radial pulse found?

Answer 19

radial side of forearm at wrist

Question 20

where is the brachial pulse found?

Answer 20

groove between biceps and triceps, in bend of elbow

Question 21

where is the carotid pulse found?

Answer 21

the medial edge of sternocleidomastoid muscle in lower third of neck

Question 22

heart rate is sometimes assessed by auscultating heart, which is known as ___

Answer 22

apical pulse

Question 23

where is the apical pulse found

Answer 23

located over the 5th intercostal space at the midclavicular line

Question 24

true or false? men usually breathe diaphragmatically, whereas women are usually thoracic breathers

Answer 24

true.

Question 25

why should we count respirations when patients are unaware?

Answer 25

to prevent them from getting nervous and changing their breathing patterns

Question 26

factors that increase respiratory rate

Answer 26

fever, anxiety, exercise, high altitude

Question 27

should breathing be loud and labored at rest?

Answer 27

no.

Question 28

small volume of air movement in and out of lungs

Answer 28

shallow breathing

Question 29

force of blood agaisnt arterial walls

Answer 29

blood pressure

Question 30

reflects relationship between cardiac output and peripheral resisistance

Answer 30

blood pressure

Question 31

____ is the force that opposes flow of blood through vessels

Answer 31

peripheral resistance

Question 32

When arteries are narrow = peripheral resistance to blood flow is high =

Answer 32

elevated blood pressure

Question 33

blood pressure is dependent on ___ of blood, ___ blood ____, and ____ of vessel walls

Answer 33

velocity, intravascular, volume, elasticity

Question 34

how is blood pressure measured?

Answer 34

mm Hg millimeters of mercury

Question 35

maximum pressure exerted on arteries when ventricles eject blood from heart

Answer 35

systolic blood pressure

Question 36

represents minimum amount of pressure exerted on vessels when ventricles of heart relax

Answer 36

diastolic blood pressure

Question 37

blood pressure top and bottom numbers

Answer 37

top=systolic bottom=diastolic

Question 38

pulse pressure

Answer 38

difference between systolic and diastolic pressures. normally ranges from 30 mm Hg to 40 mm Hg

Question 39

orthostatic blood pressure

Answer 39

series obtained when the patient is lying, sitting, and then standing

Question 40

direct (invasive) blood pressure method

Answer 40

insertion of a small catheter into an artery that provides continuous blood pressure measurements and arterial waveforms

Question 41

when is direct blood pressure used?

Answer 41

critical care settings where continuous monitoring is required

Question 42

indirect measurement of blood pressure

Answer 42

most commonly used/ auscultation with sphygomomanometer and stethoscope or w/ noninvasive blood pressure monitoring

Question 43

when auscultating blood pressure, listen for

Answer 43

korotkoff sounds

Question 44

mechanism of blood pressure measurement

Answer 44

blood flows freely through artery until inflated cuff interrupts the flow. as it slowly deflates, nurse listens for sounds of blood pulsating through artery again.

Question 45

initial sound and point at which systolic pressure is detected

Answer 45

first korotkoff sound.

Question 46

swishing sound heard as cuff continues to deflate

Answer 46

second korotkoff sound

Question 47

korotkoff sound w/ softer thump than the first

Answer 47

3rd

Question 48

muffled, low pitched sound as cuff is further deflated

Answer 48

4th korotkoff sound

Question 49

sound which determines diastolic pressure

Answer 49

5th korokoff sound. last beat

Question 50

electronic device attached to a cuff

Answer 50

NIBP

Question 51

incidence of hypertension is twice as high in black americans than whites. true or false?

Answer 51

true

Question 52

men have higher blood pressures than women until when?

Answer 52

menopause, when women's may become higher

Question 53

blood pressure diurnal variations

Answer 53

pressure lower in early morning, peaks in late afternoon or early evening

Question 54

device that estimates oxygen saturation of hemoglobin in blood

Answer 54

pulse oximeter

Question 55

where can pulse oximeters be placed?

Answer 55

finger, toe, earlobe, nose

Question 56

by what age is adult height attained?

Answer 56

18-20 years old

Question 57

True or false? using too small of a blood pressure cuff can cause a patient's systolic blood pressure to increase 10 to 40 mmHg

Answer 57

true

Question 58

How far should a rectal thermometer go?

Answer 58

1.25 to 2.5 centimeters

Question 59

pulse strengths

Answer 59

0= absent +1 diminished +2 normal +3 full volume +4 full volume and bounding

Question 60

why should we check carotid pulses at the base of the neck?

Answer 60

taking them too high up can result in pushing on the sinuses and causing patients to faint

Question 61

how long should we count apical pulses?

Answer 61

always the full minute

Question 62

how are intercostal spaces named?

Answer 62

for the rib directly above it