Chapter 5: Pre, Boxes, Keys, Book Qs, PPT Qs, (no test bank) Flashcards
T / F: Height decreases as a person ages because the vertebral discs thin.
T
T / F: The peripheral pulse is decreased, but the tissue below will have adequate circulation.
F
The ____________ is used if the pulse and BP are difficult to auscultate or palpate.
Doppler
What is a Doppler?
A Doppler ultrasound is a noninvasive test that can be used to estimate the blood flow through your blood vessels by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells. A regular ultrasound uses sound waves to produce images, but can’t show blood flow.
___________________ measurements include height and weight.
Anthropometric
Anthropometric measurements are a series of quantitative measurements of the muscle, bone, and adipose tissue used to assess the composition of the body. The core elements of anthropometry are height, weight, body mass index (BMI), body circumferences (waist, hip, and limbs), and skinfold thickness.
T / F: Normal pulse rates remain the same across the lifespan.
False
How do normal pulse rates change across the lifespan.?
Look it up
The _______ is assessed for rate, rhythm, amplitude, and elasticity.
pulse
An oxygen ______________ level less than 85% indicates inadequate oxygenation to the tissues.
saturation
The nurse measures the blood pressure in both arms, if not contraindicated, and should report a difference of ___________ mm Hg or more between the two arms because this may be a sign of arterial obstruction.
20
T / F: The general survey includes overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, and gait.
T
T / F: Vital signs reflect patient’s health status, cardiopulmonary function, and overall function of the body.
T
Body temp is controlled by the ______ in the brain
hypothalamus
So well look for brain injuries if BP is wacky
If the body temp reading is too high or low, the next thing you do is check the patient’s chart for their _____ temperature
most recently documented
Patient must be “______ and ________” to take an oral temperature
alert, cooperative
Is the following statement true or false?
A temperature above 38.5°C in adults requires immediate assessment and rapid cooling measures.
False
Rationale: Fever above 39.5°C (103°F) in adults requires immediate assessment and rapid cooling measures. Monitor rectal temperature constantly during cooling measures to prevent a hypothermic response.
To check pulse, you palpate arterial pulse points, measuring: rate; rhythm; ______; and _____
amplitude = strength
elasticity
Why do we palpate and take a pulse first?
To establish a BASELINE for that patient
Children may have a little _____ (lower/higher) of a pulse
higher
If pulse is irregular, then check it again for how long?
A FULL MINUTE
If you have a patient on heart medications, where do you take their pulse?
On the “apical” (left center of your chest, just below the nipple)
Should you check a person’s carotid arteries at the same time? Why?
Never check both of a person’s carotid arteries at the same time because you’ll cut off their pulse. Do one at a time
What if you can’t feel a popliteal pulse, what would you check next? You’d check the ______ pedis artery because you’d want to see if it’s getting worse as you go down.
dorsalis
Amplitude = the strength of the blood flow through the vessel. It’s diff in every patient. There’s a scale 0-4.
0 means \_\_\_\_\_ 1 means \_\_\_\_\_ 2 means \_\_\_\_\_ 3 means \_\_\_\_\_ 4 is considered “\_\_\_\_\_”
0 means no pulse. 1 means diminished. 2 is normal! 3 means full and increased. 4 is considered “abounding”
Eupnea is \_\_\_\_\_\_ breathing Dyspnea is \_\_\_\_\_\_ breathing Apnea is \_\_\_\_\_\_\_ Hyperpnea is \_\_\_\_\_\_\_ breathing Bradypnea is \_\_\_\_\_\_\_ breathing
Eupnea is normal breathing Dyspnea is trouble breathing Apnea is not breathing at all Hyperpnea is deep rapid breathing Bradypnea is slow breathing
Oxygen saturation is what?
Percentage to which hemoglobin is filled with O2
When taking orthostatic BP, take it with patient lying down, then have them sit up, then wait _____ minutes = the minimum you can wait before taking BP again
2
What is the prevalence of obesity among men in the United States?
A. African American men have highest prevalence of obesity in the United States.
B. Caucasian men have highest prevalence of obesity in the United States.
C. No significant variation by race/ethnicity.
D. Mexican American men have highest prevalence of obesity in the United States.
D. Mexican American men have highest prevalence of obesity in the United States .
Rationale: Mexican American largest majority of the Hispanic population, experience in greater percentages than Caucasians being overweight and obese. Reduction of obesity is included in the Healthy People goals for many developed nations.
Fever______ (increases/decreases) the metabolic rate.
increases
Either a very fast or a very slow heart rate causes____ (more/less) blood to be circulated to the brain and body.
less
High BP______ (reduces/increases) blood supply to the brain and vital organs because it cannot get through.
reduces
The incidence of obesity has more than doubled since 1980 and an estimated _ of 3 U.S. adults are overweight
2
What is hypoxia?
Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level.
Change in _____________ is often the first indication of hypoxia.
level of consciousness
The nurse should take a patient’s vital signs:
Upon______ to a facility;
Before and after any_____ procedure;
Before, during, and after administration of medications that affect vital signs;
Per the institution’s policy or physician orders;
Any time the patient’s condition_____;
Before and after any procedure affecting vital signs.
admission
surgical
changes
What is an anthropometric measurement?
Anthropometric measurements are a series of quantitative measurements of the muscle, bone, and adipose tissue used to assess the composition of the body. The core elements of anthropometry are height, weight, body mass index (BMI), body circumferences (waist, hip, and limbs), and skinfold thickness.
When the condition of the patient is______, the nurse may delegate the tasks of obtaining anthropometric measurements and vital signs to nursing assistants.
In such cases, nurses _____ (do/don’t) retain legal responsibility for assessing findings and intervening when necessary. Principles of delegation are used.
stable
do
The patient’s subjective report of feeling feverish is usually_____ (inaccurate/accurate) . Take the patient’s temperature when he or she feels feverish or chilled.
accurate
Oral thermometers are not recommended for children younger than _ years of age.
6
____ temperature measurement is contraindicated in newborns, infants, and young children; patients who are neutropenic; patients with rectal diseases; and those who have undergone rectal surgery.
Patients with hemorrhoids and those with diarrhea should not have _____ temperatures assessed. The rectal route should also be avoided with patients who have cardiac conditions because insertion of the thermometer may cause vagal stimulation and reduce heart rate.
Rectal
rectal
The carotid pulse should be palpated only in the lower____ of the neck to avoid stimulation of the carotid sinus.
third
In cardiac emergencies, the_____ and_____ pulses are assessed.
carotid, femoral
What is pallor?
an unhealthy pale appearance.
Assess patients with dyspnea (difficulty breathing) in the position of greatest ______ to them. Repositioning may decrease the respiratory effort and promote improved oxygenation.
comfort
(in reference to breathing) High-pitched crowing sounds from tracheal or laryngeal spasm, called ______, may indicate a life-threatening emergency.
stridor
One of the most common causes of slow respiration is in patients taking ______… sometimes accidentally administered by hospital staff.
opiates
Using a cuff that is too ____ causes a falsely high BP reading; using one that is too ____ causes a falsely low BP reading.
small, large
What is the auscultatory gap?
A period in which there are no Korotkoff sounds during auscultation.
How can the nurse prevent missing the auscultatory gap?
Estimating the SBP (systolic BP)
(BP) You will hear sounds only during the period of ____ occlusion and not when the artery is totally closed or totally open. There must be some friction of the blood flowing against the artery to create the sound.
partial
Label these 1-5
Characterized by muffled or swishing sounds; these sounds may temporarily disappear, especially in patients with hypertension; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap and may cover a range of as much as 40 mm Hg. Failure to recognize this gap may cause serious errors of underestimating systolic pressure or overestimating diastolic pressure.
Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery
Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure.
The last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure.
Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, onset of this phase is considered to be the first diastolic pressure.
I = Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure.
II = Characterized by muffled or swishing sounds; these sounds may temporarily disappear, especially in patients with hypertension; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap and may cover a range of as much as 40 mm Hg. Failure to recognize this gap may cause serious errors of underestimating systolic pressure or overestimating diastolic pressure.
III = Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery
IV = Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, onset of this phase is considered to be the first diastolic pressure.
V = The last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure.
SBP less than 90, or __ mm Hg below the patient’s baseline, needs immediate attention.
30
The____ survey begins with the first moments of patient encounter, progresses through the history and physical examination, and continues with each subsequent interaction.
general
Extreme anxiety, acute distress, pallor, cyanosis, changes in mental status, and changes in vital signs may indicate the need for assistance and a____ response.
rapid
The____ survey includes overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, and gait.
general
Anthropometric measurements are most notably ____ and_____.
height, weight
____signs reflect patient health status, cardiopulmonary function, and overall function of the body.
Vital
T/F: The nurse assesses the appropriate route for temperature measurement: oral, axillary, tympanic, temporal artery, or rectal.
T
The nurse assesses the____ for rate, rhythm, amplitude, and elasticity.
pulse
Smoking, p_____, medication, neurological injury, and h_______ levels affect the respiratory rate.
positioning
hemoglobin
The nurse assesses respirations for rate, rhythm, _____ , and use of accessory muscles.
depth
An oxygen saturation level less than __% indicates inadequate oxygenation to the tissues.
92%
Age, gender, ethnicity, weight, circadian cycle, position, exercise, emotions, stress, medications, and smoking affect __.
BP
The_____ artery is commonly used to measure BP.
brachial (major blood vessel of the upper-arm)
Width of the BP cuff size should equal __% of the length of the patient’s upper arm, and length of the bladder should equal __% of the circumference of the arm.
40%
80%
T / F - Postural (orthostatic) vital signs are taken sitting, lying, and standing; orthostatic changes may indicate intravascular volume depletion.
T
A vital signs monitor is commonly used in the _____ setting.
hospital
The_____ transducer is used if the pulse and BP are difficult to auscultate or palpate.
Doppler
Vital signs change in older adults because of________ changes in the body.
physiological
The nurse assesses the following vital signs in a 78-year-old man: temperature 36.6°C, temporal; pulse 72 beats/min, regular, 2+; respirations 18 breaths/min, regular, no use of accessory muscles; BP 142/92 mm Hg.
Which of the findings is abnormal?
Pulse
BP
Respirations
Temperature
B. BP. Rationale: In older adults, both SBP and DBP increase due to increased stiffness of arterial walls. This finding is outside of the normal range. Temperature in the older adult tends to be at the lower range of normal.
The best way to assess a client’s respiration rate is by:
Place a hand over the client’s chest and count for 30 seconds
Observe and count respirations for 30 seconds and multiply by two without mentioning that you are observing the respirations.
Ask the client to breath normally for one minute.
If respirations are irregular have the client rest for 10 minutes and then recount.
C. Ask the client to breath normally for one minute. Rationale: Do not make the patient aware that you are assessing respirations. Increased awareness may alter normal respiratory pattern.
The patient’s radial pulse is weak and thready. The next action of the nurse is to
transfer the patient to a critical care unit.
notify the primary care provider.
compare findings with previous findings and opposite extremity.
assess vital signs every 15 minutes.
3.C. Compare findings to previous findings and opposite extremity. Rationale: The popliteal pulse is often difficult to palpate. Comparing to previous findings and to the opposite extremity can help determine if any acute changes have occurred.
Which of the following patients should not have a temperature measured orally?
An 84-year-old woman with diarrhea
A 30-year-old patient with an earache
A 45-year-old man with chest pain
A 62-year-old woman who has had oral surgery
4.D. A 62-year-old woman who has had oral surgery. Rationale: Oral temperature measurement is contraindicated in patients who have altered mental status, those who are mouth breathers, those who have had recent oral intake or who have recently smoked, and those who have recently undergone oral surgery.
The nurse notes an irregular radial pulse in a patient. Further evaluation includes assessing for a pulse deficit. the carotid pulse. for diminished peripheral circulation. the brachial pulse.
5.A. For a pulse deficit. Rationale: Assessing for a pulse deficit provides an indirect evaluation of the heart’s ability to eject enough blood to produce a peripheral pulse. When a pulse deficit is present, the radial pulse is less than the apical pulse.
Which actions will result in an inaccurate BP reading? Select all that apply.
Obtaining a BP immediately after the patient has entered the room
Using a BP cuff with a bladder length which is 80% of the arm circumference
Asking the patient to hold out his or her arm above heart level
Pumping the cuff 10 mm Hg above the palpated systolic BP
6.A- Obtaining a BP immediately after the patient has entered the room, C - Asking the patient to hold out his or her arm above heart level, and D - Pumping the cuff 10 mm Hg above the palpated systolic BP. Rationale: Common errors in BP measurements can occur because of physical activity, incorrect cuff size, placing the arm above or below heart level, and failure to auscultate above an auscultatory gap. It is recommended to pump the cuff 20 to 30 mm Hg above the last sound.
Adult patients may have variations in pulse rates with respirations. food intake. heat. exercise.
7.D. Exercise. Rationale: Exercise will increase heart rate because of increased metabolic demands. Sinus arrhythmia, a variation in pulse with respiration, is common among children. The pulse rate varies with respiration, speeding up during inspiration and slowing down during expiration.
An unconscious 22-year-old man arrives at the hospital after experimenting with hallucinogenic substances. His vital signs are temperature 37.2°C, orally; pulse 142 beats/min; respirations 20 breaths/min; BP 100/64 mm Hg. The patient is experiencing tachycardia. eupnea. auscultatory gap. asystole.
8.A. Tachycardia. Rationale: Tachycardia is a heart rate greater than 100 beats/min in an adult.
An auscultatory gap is defined as
a drop in the SBP of 15 mm Hg or more with position change.
a period of silence heard between Korotkoff sounds.
the difference between the apical and radial pulse.
SBP minus the DBP.
9.B. A period of silence heard between Korotkoff sounds. Rationale: The auscultatory gap is the period of no Korotkoff sounds during auscultation of BP. It is caused by stiffening of the arterioles and is common in the elderly and in those with chronic disease.
Which of the following findings during the general survey may indicate a change in mental status? Select all that apply.
Disheveled appearance
Rapid speech
Lethargy
Asymmetrical movements
10.A. Disheveled appearance; B. Rapid speech; C. Lethargy.
Rationale: The general survey provides valuable clues to the patient’s overall status. Changes in appearance, speech, and alertness may indicate a change in mental status and require further evaluation. Asymmetrical movements may indicate a stroke and a specific change in neurological status.
