Chapters 5 - vital signs

Question 1

factors that cause variations in vital signs and their measurement

Answer 1

• Age: Older adults-lower normal temp, normal pulse range but variation in rythm, shallower respirations and more rapid, oxygen saturation may need to be measured on someplace other than a finger, BP usually decreases.
• gender-after puberty: males show a higher BP but this reverses after menopause.
• cultural considerations: African Americans are 40% more likely to have high BP

Question 2

Identify risk factors for alterations in vital signs.

Answer 2

increasing age, family history, male gender, high BP, high blood cholesterol level, smoking, diabetes mellitus, being overweight and obesity, decreased activity, high-fat diet, excessive alcohol intake, elevated C-reactive protein, and elevated B-type natriuretic peptide

Question 3

What are the vital signs?

Answer 3

temperature, pulse, respiration, blood pressure

Question 4

When does the general survey first begin?

Answer 4

Begins first meeting the patient during the interview phase of the health assessment

Question 5

General survey includes…

Answer 5

• health history collected
• nursing observations
• initial impression development
• data collection plan formulation

Question 6

Why are vital signs important?

Answer 6

indicate the patient’s physiological status and response to the environment

Question 7

What is considered the 5th vital sign?

Answer 7

pain

Question 8

In what order do you take the vital signs?

Answer 8

temperature, pulse, respirations, and BP

Question 9

Assessment of vital signs help the nurse…

Answer 9

establish a baseline, monitor a patient’s condition, evaluate responses to treatment, identify problems, and monitor risks for alterations in health

Question 10

Indicators of an urgent assessment for vitals?

Answer 10

• extreme anxiety; acute distress
• pallor; cyanosis; mental status change

Question 11

Equipment needed for vital signs include…

Answer 11

• scale
• height bar
• stethoscope
• thermometer
• watch with second hand
• sphygmomanometer
• pulse oximeter
• tape measure for infants

Question 12

Risk factors for hypertension (high BP) ?

Answer 12

obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol and triglyceride levels, family history, and renal disease.

Question 13

Assessing the physical appearance of the patient includes…

Answer 13

• overall appearance
• hygiene; dress
• skin color; body structure, development
• behavior; facial expressions
• level of consciousness; speech

Question 14

anthropmetric measurements

Answer 14

height and weight
- calculation of BMI whether considered, obese or underweight

Question 15

Purpose of vital sign measurements?

Answer 15

• reflects health status
• cardiopulmonary function
• overall body function
• provides baseline measurements

Question 16

What is the normal range of body temperature? ( oral temp)

Answer 16

approximately 36.5 C - 37 C
( 97.7 F - 98.6 F )

Question 17

Normal range for axillary temperature?

Answer 17

35.9°-36.9°C
(96.7°-98.5°F)

Question 18

Normal range for rectal temperature?

Answer 18

37.1°-38.1°C
(98.7°-100.5°F)

Question 19

Normal range for tympanic temperature?

Answer 19

36.8°-37.8°C
(98.2°-100°F)

Question 20

Normal range for temporal temperature?

Answer 20

37.1°-38.1°C
(98.7°-100.5°F)

Question 21

What is pulse?

Answer 21

a throbbing sensation palpated over peripheral artery, auscultated over cardiac apex

Question 22

Palpate the pulse points to measure…

Answer 22

rate; rhythm; amplitude; elasticity

Question 23

Abnormal findings of pulse include…

Answer 23

• tachycardia ( high pulse )
• bradycardia ( low pulse )
• asystole ( no pulse )

Question 24

Normal ranges for heart rate varied on ages…

Answer 24

• newborn 70- 190
• infant 80-160
• toddler 80-130
• child 70-115
• preteen 65-110
• teen 55-105
• adult 60-100

Question 25

Scale description for pulse strength

Answer 25

0 - Nonpalpable or absent
1+ - Weak, diminished, and barely palpable
2+ - Normal, expected
3+ - Full, increased
4+ - Bounding

Question 26

Respirations is the _________

Answer 26

act of breathing

Question 27

Normal range for respiratory rate?

Answer 27

12-20 breaths per minute

Question 28

dyspnea

Answer 28

difficult or labored breathing

Question 29

Tachypnea

Answer 29

fast breathing

Question 29

bradypnea

Answer 29

slow breathing

Question 30

Hyperventilation

Answer 30

increased rate and depth of breathing

Question 30

Systolic Blood Pressure (SBP)

Answer 30

Left ventricular contraction: maximum pressure

Question 30

hypoventilation

Answer 30

decreased rate or depth of air movement into the lungs

Question 30

apnea

Answer 30

absence of breathing

Question 31

Normal pulse oximetry

Answer 31

92%-99%

Question 32

diastolic blood pressure

Answer 32

left ventricular relaxation: minimum pressure

Question 33

Factors that contribute to blood pressure include…

Answer 33

• cardiac output (how well the heart is beating)
• circulating blood volume; viscosity
• vessel wall elasticity (poor veins=lower pressure)

Question 34

average BP for adults

Answer 34

120/80 mmHg; with a range of 90 to 120 mm Hg SBP and 60 to 80 mm Hg DBP

Question 35

Influencing factors of BP

Answer 35

• age, gender, ethnicity, weight, diurnal cycle
• position, exercise, emotions, stress
• medications, smoking

Question 36

Abnormal findings for BP are…

Answer 36

Hypertension (high)
Hypotension (low)

Question 37

Orthostatic (postural) hypotension

Answer 37

rapid lowering of the blood pressure as a result of changing positions

Question 38

The doppler transducer is used if?

Answer 38

pulse and BP are difficult to auscultate or palpate.