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fundamentals of nursing > exam 1: chapter 26 (vital signs) > Flashcards

exam 1: chapter 26 (vital signs) Flashcards

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1
Q

vital signs are indicators of __ (physiologic/pathologic/anatomical) function and reflect the __ (mental status/ADLs/health status) of a person

A

physiologic; health status

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2
Q

normal oral temperature is __

A

37 degrees Celsius or 98.6 degrees Fahrenheit

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3
Q

normal BP is __

A

120/80

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4
Q

normal R is __

A

12-20 breaths/min

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5
Q

normal HR/PR is __

A

60-100bpm (80 avg)

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6
Q

out of the following options, when do we assess vital signs? select all that apply.
a. before administering medication
b. on admission
c. before any surgical procedure
d. ambulation after surgery
e. change in pt’s condition
f. based on facility policy and procedures
g. LOC

A

all of the above

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7
Q

thermoregulation occurs in the __ (medulla/hypothalamus/thyroid gland)

A

hypothalamus

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8
Q

__ (pulse rate/blood pressure/temperature) can be defined by the difference in heat __ (produced/deduced) and __ (gained/lost)

A

temperature; produced; lost

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9
Q

temperature is generated by __ (alkaline/metabolic/physiologic) processes

A

metabolic

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10
Q

true or false. core temperature is lower than surface body temperature

A

false. core temp is HIGHER than surface body temp

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11
Q

the 5 factors that affect temperature are __ (hint: capse)

A

circadian rhythms | age and biological sex | physical activity | state of health | environmental temp

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12
Q

older adults have lower body temps bc __

A

they have a loss in thermoregulatory control

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13
Q

true or false. the very young and old are more affected by environmental temperature

A

true

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14
Q

why do pregnant women have a higher body temp than the average person?

A

hormones

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15
Q

match the following thermometers that measure temperature with their definition. one or more answers can be used:
a. electronic thermometer
b. disposable thermometer
c. tympanic membrane thermometer
d. temporal artery thermometer

  1. uses infrared sensors to detect heat. probe covered and inserted into the ear for 1-3secs
  2. measures oral, rectal, or axillary body temperature over a few seconds to 1min depending on site and product
  3. captures heat emitted by skin over the temporal artery
A

a. 2
b. 2
c. 1
d. 3

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16
Q

the 5 routes to measure temperature are: __ (hint: oratt)

A

oral | rectal | axillary | temporal | tympanic

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17
Q

rank the routes of measurement in order from lowest to highest for temperature:

a. oral
b. rectal
c. axillary
d. temporal artery
e. tympanic

A

c, a, e, b, d

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18
Q

oral temp is between __

A

97.7 - 99.5 degrees Fahrenheit

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19
Q

axillary temp is between __

A

96.7 - 98.5 degrees Fahrenheit

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20
Q

tympanic membrane temp is between __

A

98.2 - 100 degrees Fahrenheit

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21
Q

rectal temp is between __

A

98.7 - 100.5 degrees Fahrenheit

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22
Q

temporal artery temp is between __

A

98.7 - 100.5 degrees Fahrenheit

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23
Q

true or false. HYPERthermia is a decrease in body temp

A

false. HYPOthermia is a decrease in body temp

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24
Q

what nursing intervention would you take if a person has hypothermia?
a. take them out of the environment
b. put blankets on them
c. give them medicine
d. make them move

A

b. put blankets on them

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25
Q

a pt has hyperthermia. as the nurse, which nursing intervention is most appropriate for you to do?
a. put blankets on them
b. give them heating packs
c. take them out of the environment
d. give them ice packs

A

c and d

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26
Q

__ (temperature/pulse/blood pressure) is regulated by the __ (ans/sns) via the __ (SA/AV/MV) node

A

pulse; ans; sa

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27
Q

true or false. parasympathetic stimulation decreases heart rate

A

true

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28
Q

true or false. sympathetic stimulation decreases heart rate

A

false. sympathetic stimulation INCREASES heart rate

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29
Q

pulse rate can be defined by the number of __ (vasoconstriction/contractions/dilations) over a peripheral artery in 1 min

A

contractions

30
Q

which of the following are factors that affect pulse rate?
a. physical activity
b. fever and stress
c. age an biological sex
d. meds
e. disease
f. diet

A

a-e

31
Q

tachycardia is between __ and __ bpm

A

100;180

32
Q

bradycardia is __(</>) 60bpm

A

<

33
Q

the difference between radial and apical pulse is known as __ (pulse rate/pulse deficit)

A

pulse deficit

34
Q

pulse quality is measured on a range of __ to __

A

0;3

35
Q

a pulse of 0 means __

A

absent

36
Q

a pulse of 1 means __

A

weak, diminished

37
Q

a pulse of 2 means __

A

normal, brisk

38
Q

a pulse of 3 means __

A

bounding

39
Q

pulse rhythm can either be __ or __

A

regular; irregular

40
Q

name the 8 sites on the body where a pulse can be found (hint: go from head to toe)

A

temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis

41
Q

a pt is undergoing tachycardia. why might they be experiencing this? select all that apply.
a. htn
b. elevated temp
c. hypoxia
d. exercise
e. pain
f. prolonged application
g. strong emotions
h. meds

A

all of the above

42
Q

what are some reasons as to why a pt may be experiencing bradycardia? select all that apply.
a. aging
b. increased icp
c. meds
d. mi
e. vagal stimulation
f. suctioning
g. sa node block
h. severe pain
i. hypothermia

A

all of the above

43
Q

respirations are activated by impulses from __ (sa nodes/chemorecptors/medulla)

A

chemoreceptors

44
Q

respiration is controlled by respiratory centers in the __ (medulla/cerebellum/frontal lobe) and __ (pons/temporal lobe/brain stem)

A

medulla; pons

45
Q

the most powerful stimulant of respiration is increased __(oxygen/carbon dioxide/nitrogen)

A

carbon dioxide

46
Q

match the appropriate respiratory components with their definitions:
a. diffusion/oxygenation
b. ventilation
c. perfusion
1. air movement in & out of lungs
2. o2 and co2 exchange between ALVEOLI OF LUNGS and CIRCULATING BLOOD
3. o2 and co2 exchange between CIRCULATING BLOOD and TISSUE CELLS

A

a. 2
b. 1
c. 3

47
Q

age, acid-base balance, acute pain, anxiety, anemia, exercise, increased altitude, meds, respiratory disease are all factors that affect respiration. true or false?

A

true

48
Q

eupnea is __ (unlabored breathing/decreased R/increased R/changes in breathing when sitting or standing)

A

unlabored breathing

49
Q

tachypnea is __
a. unlabored breathing
b. periods when no breathing occurs
c. labored breathing
d. increased R

A

d

50
Q

bradypnea is __
a. 12-20 breaths
b. changes in breathing when sitting or standing
c. decreased R
d. periods when no breathing occurs

A

c

51
Q

apnea is __

A

periods when NO breathing occurs

52
Q

dyspnea is __
a. decreased R
b. difficult/labored breathing
c. changes in breathing when sitting or standing
d. increased R

A

b

53
Q

orthopnea is __
a. changes in breathing when sitting or standing
b. periods when no breathing occurs
c. increased r
d. decreased r

A

a

54
Q

cheyne-stokes or biot’s. fast, shallow breathing followed by apnea and then slow, heavier breathing

A

cheyne-stokes

55
Q

unpredictable irregularities in breathing alternates. biot’s or cheyne-stokes.

A

biot’s

56
Q

factors that affect bp are: __ (hint: abcdeefw)

A
  • age, biological sex, race
  • body position
  • circadian rhythm
  • drugs/meds
  • emotional state
  • exercise
  • food intake
  • weight
57
Q

an elevated bp is __
a. 120/80
b. sys: 120-129 dias: <80
c. sys: 130-139 or dias: 80-89
d. sys: 140+ or dias: 90+

A

b. sys: 120-129 and dias: <80

58
Q

stage 1 htn has a bp of __
a. sys: 120-129 dias: <80
b. sys: 130-139 or dias: 80-89
c. sys: 140+ or dias: 90+
d. sys: >180 and/or dias: >120

A

b. sys: 130-139 or dias: 80-89

59
Q

a hypertensive crisis has a bp of __
a. sys: 120-129 dias: <80
b. sys: 130-139 or dias: 80-89
c. sys: 140+ or dias: 90+
d. sys: >180 and/or dias: >120

A

d. sys: >180 and/or dias: >120

60
Q

stage 2 htn has a bp of __
a. sys: 120-129 dias: <80
b. sys: 130-139 or dias: 80-89
c. sys: 140+ or dias: 90+
d. sys: >180 and/or dias: >120

A

c. sys: 140+ or dias: 90+

61
Q

htn is a dysfunction of the __ (ans/sns/neurohormonal) system

A

neurohormonal

62
Q

__ (primary/secondary) htn is an increase above normal bp w/no known cause

A

primary

63
Q

__ (primary/secondary) htn is caused by another disease

A

secondary

64
Q

you must assess htn based on __ (1/2/3) readings

A

2

65
Q

of the following, which are the correct positions for measuring bp?
a. seated for ~5mins
b. back supported
c. feet on floor
d. arm supported - horizontal
e. bp cuff @ heart level
f. legs crossed

A

a-e

66
Q

the pulse oximeter measures __
a. the amount of oxygen in the lungs
b. percentage of hemoglobin
c. the oxygen saturation of blood

A

b and c

67
Q

htn is most likely to be seen in a(n) __
a. child
b. teenager
c. older adult
d. elderly

A

c. older adult

68
Q

orthostatic hypotension is more common in __
a. children
b. teenagers
c. older adults
d. elderly

A

c. older adults

69
Q

older adults have a __ (higher/lower) resting heart rate

A

higher

70
Q

older adults have a(n) __ (decreased/increased) rate of breathing

A

increased

71
Q

older adults have a __ (higher/lower) body temperature

A

lower

fundamentals of nursing (17 decks)

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