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Nursu 461 / Foundations > Exam 1 / Part 4 > Flashcards

Exam 1 / Part 4 Flashcards

1
Q

Name the vital signs.

A

Vital signs are measurements of the body’s most basic functions and include temperature, pulse, respiration, and blood pressure. Many health care facilities also consider pain and oxygen saturation vital signs.

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2
Q

What is the difference btwn Systolic BP and Diastolic BP?

A 
Blood pressure (BP) reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart. 
Systolic BP (SBP) occurs during ventricular systole of the heart, when the ventricles force blood into the aorta, and represents the maximum amount of pressure exerted on the arteries. 
Diastolic BP (DBP) occurs during ventricular diastole of the heart, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries.
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3
Q

What are the physiological responses re temperature.

A

a. The neurological and cardiovascular systems work together to regulate body temperature. Disease or trauma of the HYPOthalamus or spinal cord will alter temperature control. (The hypothalamus is the thermostat; thee anterior controls heat loss, posterior controls heat production.)
b. The tympanic membrane, rectum, and urinary bladder are core temperature measurement sites. (TRU to the Core haha)
c. The skin, mouth, and axillae are surface temperature measurement sites.

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4
Q

What is the expected range of oral temperature readings?

A

An oral temperature range of 96.8° to 100.4° F is acceptable. The average is 98.6° F.

  • *Age-specific: Use this site for clients who are 4 years of age and older.
  • *Note: Do not use this site for clients who breathe through their mouth or have experienced trauma to the face or mouth.
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5
Q

What is the expected range of temporal and rectal temperature readings?

A

Rectal temperatures are usually 0.9° F HIGHER than oral temperatures. Temporal is 1° F
**PR: Assist the client to Sims’ position with the upper leg flexed. Do not use for clients who have diarrhea, are on bleeding precautions, or have rectal disorders.

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6
Q

What is the expected range of axillary and tympanic temperature readings?

A

Axillary and tympanic temperatures are usually 0.9° F LOWER than oral temperatures.

  • *Age-specific: the American Academy of Pediatrics recommends screening infants 3 MONTHS old and younger by measuring axillary temperature initially.
  • *Pull the ear up and back (for an adult) or down and back (for a child who is younger than 3 YEARS old).
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7
Q

How should a newborn’s temperature read?

A

Newborns have a large surface-to-mass ratio; therefore, they lose heat rapidly to the environment. Newborns’ temperatures should be between 97.7° and 99.5° F.

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8
Q

What should be considered when reading temperatures of older adults?

A

Older adult clients experience a loss of subcutaneous fat that results in lower body temperatures and feeling cold. Their average body temperature is 96.8° F. Older adult clients are more likely to develop adverse effects from extremes in environmental temperatures (heat stroke, hypothermia). It also takes longer for body temperature to register on a thermometer due to changes in temperature regulation.

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9
Q

Can hormones affect temperature?

A

Hormonal changes may influence temperature. In general, temperature rises slightly with ovulation and menses. With menopause, intermittent body temperature may increase by up to 7.2° F.

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10
Q

How long should the nurse wait to take the temperature of a patient who just finished eating, drinking, or smoking?

A

Recent food or fluid intake and smoking can interfere with accurate measurement of body temperature, so it is best to wait 20 to 30 min before measuring temperature.

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11
Q

When is a a fever considered harmful?

A

Fever is usually not harmful unless it exceeds 102.2° F.

Remember, pyrexia (fever) is an important defense mechanism.

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12
Q

Which classes of medications are used to treat hypERthermia?

A
  1. Administer antibiotics (after obtaining specimens for blood culture).
  2. Antipyretics (aspirin, acetaminophen [Tylenol], ibuprofen [Advil]). Do not give aspirin to manage fever in children and adolescents who may have a viral illness (influenza, chickenpox) due to the risk of Reye syndrome.
    * *Remember: Heatstroke (104° F or higher).
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13
Q

What is hypOthermia?

A

Hypothermia is a body temperature below 95° F.

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14
Q

Which division of the nervous system affects pulse?

Remember motor neurons of the PNS affect both the somatic ns and the automatic ns.

A

The autonomic nervous system controls the heart rate. The parasympathetic nervous system lowers the heart rate, and the sympathetic nervous system raises the heart rate.

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15
Q

List the 4 aspects of pulse.

A
  1. Rate – The number of times per minute you feel or hear the pulse.
  2. Rhythm – The regularity of impulses.
  3. Strength (amplitude) – Reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system. The strength of the impulse should be the same from beat to beat. Grade strength on a scale of 0 to 4. Interpret this scale as follows: 0 = Absent, 1+ = Weak, 2+ = Expected, 3+ =Strong, 4+ = Bounding
  4. Equality – Peripheral pulse impulses should be symmetrical in quality and quantity from the right side of the body to the left.
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16
Q

The expected reference range for a pulse of an adult client is 60 to 100/min at rest. What are terms used to describe deviations from this range?

A

a. Tachycardia – above the expected range or faster than 100/min
b. Bradycardia – below the expected range or slower than 60/min
c. Dysrhythmia – an irregular heart rhythm, generally with an irregular radial pulse
* *For infants, the expected pulse rate is 120 to 160/min.
* *The average pulse for a 12- to 14-year-old child is 80 to 90/min.

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17
Q

Define pulse deficit.

A

The difference between the apical rate and the radial rate. To determine the pulse deficit accurately, two clinicians should measure the apical and radial pulse rates simultaneously.

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18
Q

How should a pulse be taken when it is regular V. irregular?

A

a. If the peripheral pulsation is regular, count the rate for 30 sec and multiply by 2.
b. If the pulsation is irregular, count for a full minute and compare the result to the apical pulse rate.
* *Use the apical site for assessing the heart rate of an infant, rapid rates (faster than 100/min), irregular rhythms, and rates prior to the administration of cardiac medications.

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19
Q

What is ventilation?

A

The exchange of oxygen and carbon dioxide in the lungs. Measure ventilation with the respiratory rate, rhythm, and depth.

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20
Q

What is diffusion?

A

The exchange of oxygen and carbon dioxide between the alveoli and the red blood cells. Measure diffusion with pulse oximetry.

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21
Q

What is perfussion?

A

The flow of blood to and from the pulmonary capillaries. Measure perfusion with pulse oximetry.

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22
Q

Name three ways to describe respiration.

A
  1. In rate – The number of full inspirations and expirations in 1 min. The expected reference range for adults is 12 to 20/min. School-age children have respiratory rates of 20 to 30/min. Newborns have rates of 30 to 60/min.
  2. In depth – The amount of chest wall expansion that occurs with each breath. Altered depths are deep or shallow.
  3. In rhythm – The observation of breathing intervals. For adults, expect a regular rhythm (eupnea) with an occasional sigh.
    * *Bradypnea (slow), Tachypnea (fast), Apnea (suspended), Cheyne-Stokes (alternating), Kussmaul’s (deep & labored), Biot’s (short, shallow breaths with periods of apnea)
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23
Q

Which classes of medications affect respiration?

A

Medications such as opioids, sedatives, bronchodilators, and general anesthetics decrease the respiratory rate and depth. Respiratory depression can be a serious adverse effect. Amphetamines and cocaine increase rate and depth.
**Remember, the medulla oblongata regulates respiration.

24
Q

Describe how to check respiration.

A
  1. Perform hand hygiene and provide privacy.
  2. Place the client in semi-Fowler’s position, being sure the chest is visible. Have the client rest an arm across the abdomen, or place a hand directly on the client’s abdomen.
  3. Observe one full respiratory cycle, look at the timer, and then begin counting the rate.
  4. Count a regular rate for 30 seconds and multiply by 2. Count the rate for 1 min if irregular, faster than 20/min, or slower than 12/min.
  5. Note depth (shallow, normal, or deep) and rhythm (regular or irregular).
25
Q

What might cause a low SaO2 and what are some effects?

A

Impaired oxygen-carrying capacity of the blood that occurs with anemia or at high altitudes results in increases in the respiratory rate and alterations in rhythm to compensate.

26
Q

What is pulse oximetry?

A

This is a noninvasive, indirect measurement of the oxygen saturation (SaO2) of the blood. The expected reference range is 95% to 100%, although acceptable levels for some clients range from 91% to 100%. Some illness states may even allow for an SaO2 of 85% to 89%.

27
Q

What are the principle determinants of Blood Pressure?

A

The principal determinants of blood pressure (BP) are cardiac output (CO) and systemic vascular resistance (SVR).
BP = CO x SVR.

28
Q

What is classified as normal BP?

A

SBP is less than 120mmHg, AND

DBP is less than 80 mmHg

29
Q

Give the BP range for prehypertension.

A

SBP = 120-139, or
DBP = 80-89
**Remember: Older adult clients may have a slightly elevated systolic pressure due to decreased elasticity of blood vessels.

30
Q

Give the BP range for Stage 1 HTN. (Remember, if the readings are elevated on at least 3 separate occassion over several weeks, the client has HTN.)

A 
SBP = 140-159, or
DBP = 90-99
31
Q

What is classified as Stage 2 HTN.

A

SBP is greater than 160, or

DBP is greater than 100

32
Q

What is classified as hypOtension?

A

Hypotension is a BP that is below normal (systolic < 90 mm Hg) and can be a result of fluid depletion, heart failure, or vasodilation.

33
Q

Define pulse pressure.

A

Pulse pressure is the difference between the systolic and the diastolic pressure readings.

34
Q

Define Orthostatic Hypotension.

A

Postural (orthostatic) hypotension is a BP that falls when a client changes position from lying to sitting or standing, and it may result from various causes (peripheral vasodilation, medication side effects, fluid depletion, anemia, prolonged bed rest). The client has orthostatic hypotension if the SBP decreases more than 20 mm Hg and/or the DBP decreases more than 10 mm Hg with a 10% to 20% increase in the heart rate.

35
Q

Do circadian rhythms affect BP?

A

Circadian (diurnal) rhythms affect BP, with BP usually lowest in the early morning hours and peaking during the later part of the afternoon or evening.

36
Q

Does ethnicity affect BP?

A

African Americans have a higher incidence of hypertension in general and at earlier ages.

37
Q

Does gender affect BP?

A

Adolescent to middle-age men have higher BPs than their female counterparts. Postmenopausal women have higher BPs than their male counterparts.

38
Q

Name the classes of drugs that can affect BP.

A

Medications such as opiates, antihypertensives, and cardiac medications can lower BP. Cocaine, smoking, cold medications, oral contraceptives, and antidepressants can raise BP.

39
Q

Describe an appropriately sized cuff.

A

Apply the BP cuff 2 cm above the antecubital space with the brachial artery in line with the marking on the cuff. The width of the cuff should be 40% of the arm circumference at the point where the cuff is wrapped. The bladder (inside the cuff) should surround 80% of the arm circumference of an adult and the whole arm for a child. Cuffs that are too Large give a falsely Low reading, and cuffs that are too Small give a falsely (Sky-)high reading.

40
Q

Which arm should the nurse use to determine BP?

A

Initially measure BP in both arms. If the difference is more than 10 mm Hg, use the arm with the higher reading for subsequent measurements. This difference may indicate a vascular problem.

41
Q

How should the client prepare for a BP reading?

A

The client should:

a. Not smoke or drink any caffeine for 30 min prior to measurement.
b. Rest for 5 min before measurement.
c. Sit in a chair, with the feet flat on floor, the back and arm supported, and the arm at heart level.

42
Q

How should the nurse respond to unexpected BP readings?

A
    • It is helpful to measure the BP again near the end of an encounter with the client. Earlier pressures may be higher due to the stress of the clinical setting.
    • Recheck BPs when you use an automatic device.
    • Deflate the cuff completely between attempts. Wait at least 1 full min before reinflating the cuff. Air trapped in the bladder can cause a falsely High reading (Air is high in the sky).
43
Q

Describe the DASH diet recommended for hypertensive patients.

A

DASH (Dietary Approaches to Stop Hypertension) diet

  1. Restrict sodium (Na) intake.
  2. Consume adequate potassium, calcium, and magnesium (K, Ca, Mg). These minerals help lower BP.
  3. Restrict cholesterol and saturated fat intake.
44
Q

When and how often should the nurse assess vital signs?

A

How often you routinely assess vital signs and how you collect them varies with institutional and agency policies, as well as in certain situations where you must establish a baseline or evaluate changes in patient’s condition. Typically, you would assess vital signs on a patient’s admission to your facility or agency, throughout the process of reassessing and evaluating changes in the patient’s condition, and in emergency or critical-care situations. Assess vital signs any time a patient loses consciousness, before and after any surgical or invasive diagnostic procedure, before and after any activity that can alter a patient’s condition, and before and after administering medications that affect a patient’s cardiovascular and respiratory function.

45
Q

You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse’s most appropriate advice would be to
A. Take a rectal temperature.
B. Take the oral temperature as planned.
C. Advise the patient to drink a glass of cold water.
D. Wait 30 minutes and take an oral temperature.

A

D. Wait 30 minutes and take an oral temperature.

46
Q

Name ten common pulse sites.

A
  1. temporal
  2. carotid
  3. apical
  4. brachial
  5. radial
  6. ulnar
  7. femoral
  8. popliteal
  9. posterior tibial
  10. dorsalis pedis.
47
Q

You notice that a teenager has an irregular pulse. The best action you should take includes
A. Reading the history and physical.
B. Assessing the apical pulse rate for 1 full minute.
C. Auscultating for strength and depth of pulse.
D. Asking whether the patient feels any palpitations or faintness of breath.

A

B. Assessing the apical pulse rate for 1 full minute.

48
Q

List restorative/continuing care measures to prevent pulmonary illness.

A
  1. Mobilize their secretions
  2. Prevent atelectasis (lung collapse)
  3. Hydration
  4. Incentive Spirometry Q1h
  5. Directed coughing techniques TCDB (turn, cough, deep breath) Q2h, Cascade cough, quad cough
49
Q

A postoperative patient is breathing rapidly. You should immediately
A. Call the physician.
B. Count the respirations.
C. Assess the oxygen saturation.
D. Ask the patient if he feels uncomfortable.

A

C. Assess the oxygen saturation.

50
Q 
When assessing the blood pressure of a school-aged child, using an adult cuff of normal size will affect the reading and produce a value that is
A. Accurate.
B. Indistinct.
C. Falsely low.
D. Falsely high.
A

C. Falsely low.

51
Q 
A client has an oral temperature of 99.6°F.  What is the first nursing intervention?
A.  Remove some of her clothing
B.  Assess her further for infection
C.  Evaluate the room temperature
D.  Add humidity to the environment
A

B. Assess her further for infection

52
Q 
When is the risk of developing hypothermia not increased?
A.  Excessive use of alcohol  
B.  Inactivity
C.  Malnutrition  
D.  Peripheral vasodilation
A

D. Peripheral vasodilation

53
Q

T or F. The age-related diminished ability of the kidneys to conserve water and the common occurrence of inadequate fluid intake in older adults exacerbate the effects of hypothermia.

A

True

54
Q

What is the single most important intervention for preventing hypothermia or hyperthermia?
A. Keep humidity levels at 80% at all times of the year
B. Maintain the environmental temperature at 75°F
C. Winterize the home in areas where the climate may reach freezing temperatures
D. Monitor body temperatures on a daily basis in areas where high temperatures are common

A

B. Maintain the environmental temperature at 75°F

55
Q 
A nursing student is taking a blood pressure on a patient with a blood pressure cuff that is too narrow. The BP’s range over the past 24 hours is 132/64 to 126/72. Which of the following blood pressure readings made by the student is most likely caused by the incorrect choice of BP cuff?
A. 96/40
B. 110/66
C. 130/70
D. 156/82
A

D. 156/82

Nursu 461 / Foundations (5 decks)

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