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NR224 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What is the difference in vital signs for pediatric patients vs. adult patients?

A

Peds have HIGHER RR & HR than adults, and LOWER BP than adults

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2
Q

Changes in vital signs can…

A

be based on environmental temperature, physical exertion, or effects of illness.

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3
Q

Consider a clients condition when assessing vital signs by…

A
  • Determining when, where, how, and by whom vitals will be measured.
  • Keep assessment frequency to a minimum (increase assessment if patients condition worsens)
  • Nurse is responsible for judging if increased frequency of assessment is necessary.
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4
Q

When taking considerations for vital signs, the nurse should assess client status by…

A
  • clients baseline, time of admission, and routine.
  • review of/change in condition
  • before, during, and after certain meds and/or blood administration.
  • a physician order or in prep for physician exam.
  • facility standard/policy
  • before, during, and after an invasive procedure.
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5
Q

When will delegating vital sign measurements be acceptable?

A
  • if client is stable
  • before delegating, nurse must review V/S data
  • a nurse CANNOT delegate apical pulse measurement
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6
Q

What vital sign is interrelated with INCREASED TEMPERATURE?

A

INCREASED HEART RATE;
INCREASED REPIRATORY RATE;
INCREASED BLOOD PRESSURE

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7
Q

What vital sign is interrelated with INCREASED BLOOD PRESSURE?

A

INCREASED HEART RATE;
INCREASED RESPIRATORY RATE

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8
Q

Normal range in adults for Pulse rate

A

60-100 beats per minute

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9
Q

Normal Temperature range in adults

A

Oral & Tympanic: 37C/96.8F
Rectal: 37.5C/99.5F
Axillary: 36.5C/97.7F

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10
Q

Normal range for Respirations

A

12-20 breaths per minute

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11
Q

Normal Pulse oximetry

A

over 95%

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12
Q

normal BP

A

120/80

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13
Q

Normal pulse pressure

A

30-50 mm Hg;
Pulse pressure is calculated by subtracting your diastolic blood pressure measurement from your systolic blood pressure measurement.

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14
Q

When compared to adults, which vital signs in infants and children differ?

A
  • Pulse and RR HIGHER
  • BP LOWER
  • Brachial and apical pulse= best sites
  • RR less regular
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15
Q

Priority nursing diagnoses include…

A
  • Risk for imbalanced body temp
  • ineffective thermoregulation
  • activity intolerance
  • anxiety
  • decreased cardiac output
  • deficient or excess fluid volume
  • impaired gas exchange
  • acute pain
  • ineffective peripheral tissue perfusion
  • risk of injury
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16
Q

temperature is the measurement of the difference between…

A

heat production and heat loss

17
Q

Which part of the brain regulates the body’s temperature?

A

hypothalamus

18
Q

any temperature below 97.6 F and/or higher than 100.6 F is…

A

an abnormal reading

19
Q

Any temp measured below 96 or over 104 on a patient who appears normal means the nurse has an…

A

incorrect reading

20
Q

Deep tissue (core body) temperature is…

A

constant

21
Q

What kind of temperature is dependent on blood flow to the skin?

A

surface body temperature

22
Q

Examples of Radiation heat loss (heat transferred b/t 2 objects w/o direct contact) include…

A
  • cool surgical room while client’s skin is exposed
  • temp in patient’s room warmer than the skin, body absorbs heat through radiation.
  • removing patient’s clothing promotes radiant heat loss.
23
Q

Examples of conductive (heat transferred from one object to another through direct contact) heat loss includes…

A

person using a fan to cool down

24
Q

Heat loss due to evaporation includes…

A

perspiration

25
Q

Basal metabolic rate

A

heat produced by body at absolute rest

26
Q

the absence of thyroid hormones affects basal metabolic rate by

A

reducing BMR in half, meaning less heat production

27
Q

Why is a man’s basal metabolic rate higher than a womans?

A

men have higher amounts of testosterone

28
Q

BMR increases during exercise which means that

A

heat production increases

29
Q

Shivering (involuntary skeletal muscle movement)

A

increases body temperature

30
Q

Non-shivering Thermogenesis

A
  • Those who cannot shiver to produce heat
  • Neonates (babies) use brown fat to produce heat
31
Q
A

NR224 (1 decks)

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