exam 1: chapter 26 (vital signs) Flashcards by Clare Alanguilan

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

physiologic; health status

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normal oral temperature is __

37 degrees Celsius or 98.6 degrees Fahrenheit

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normal BP is __

120/80

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normal R is __

12-20 breaths/min

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normal HR/PR is __

60-100bpm (80 avg)

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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

all of the above

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

hypothalamus

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

temperature; produced; lost

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

metabolic

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

false. core temp is HIGHER than surface body temp

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

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

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older adults have lower body temps bc __

they have a loss in thermoregulatory control

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

true

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

hormones

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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

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

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

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

oral | rectal | axillary | temporal | tympanic

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

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

c, a, e, b, d

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oral temp is between __

97.7 - 99.5 degrees Fahrenheit

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axillary temp is between __

96.7 - 98.5 degrees Fahrenheit

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tympanic membrane temp is between __

98.2 - 100 degrees Fahrenheit

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rectal temp is between __

98.7 - 100.5 degrees Fahrenheit

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temporal artery temp is between __

98.7 - 100.5 degrees Fahrenheit

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true or false. HYPERthermia is a decrease in body temp

false. HYPOthermia is a decrease in body temp

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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

b. put blankets on them

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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

c and d

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

pulse; ans; sa

true or false. parasympathetic stimulation decreases heart rate

true

true or false. sympathetic stimulation decreases heart rate

false. sympathetic stimulation INCREASES heart rate

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

contractions

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-e

tachycardia is between __ and __ bpm

100;180

bradycardia is __() 60bpm

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

pulse deficit

pulse quality is measured on a range of __ to __

0;3

a pulse of 0 means __

absent

a pulse of 1 means __

weak, diminished

a pulse of 2 means __

normal, brisk

a pulse of 3 means __

bounding

pulse rhythm can either be __ or __

regular; irregular

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

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

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

all of the above

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

all of the above

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

chemoreceptors

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

medulla; pons

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

carbon dioxide

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. 2 b. 1 c. 3

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

true

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

unlabored breathing

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

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

apnea is __

periods when NO breathing occurs

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

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

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

cheyne-stokes

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

biot's

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

- age, biological sex, race - body position - circadian rhythm - drugs/meds - emotional state - exercise - food intake - weight

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+

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

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

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

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

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

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

c. sys: 140+ or dias: 90+

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

neurohormonal

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

primary

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

secondary

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

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-e

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

b and c

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

c. older adult

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

c. older adults

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

higher

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

increased

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

lower