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N200 > N200 Quiz 1 Chapter 29 > Flashcards

N200 Quiz 1 Chapter 29 Flashcards

1
Q

Vital signs are a quick and efficient way of (3)

A
  1. Monitoring a client’s condition
  2. Identifying problems
  3. Evaluating the client’s response to intervention.
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2
Q

When do we assess vital signs? (4)

A
  1. upon admission/entry baseline
  2. w/ any change in health status (ie “i feel dizzy or faint”)
  3. pre and post surgery; pre and post any nursing interventions
  4. ordered vital signs, whatever the minimum for facility or ward.
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3
Q

What are the 6 vital signs we assess?

A
  1. Temperature
  2. Pulse
  3. Respirations
  4. blood pressure
  5. oxygen saturation
  6. Pain
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4
Q

What are the 12 guidelines for measing Vital Signs?

A
  1. Delegation: The nurse caring for the patient is responsible for the vital signs. if you delegate you must review and evaluate results. Can’t delegate all vitals. Know what and to whom you can delegate.
  2. Proper functioning equipment (maintained)
  3. Equipment appropriate to the client Ex. don’t use child cuff on Adult
  4. What are the client’s normal ranges?
  5. Medical history and medications
  6. Environmental factors
  7. Systematic approach
  8. Frequency of measurement
  9. Indications for medication administration
  10. ANALYZE AND INTERPRET significant changes
  11. COMMUNICATE significant changes
  12. Educate the client and family about their vital signs (1st must assess level of knowledge before you teach so they don’t ignore you.)
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5
Q

If a patient smoked or drank a cold beverage prior to vital sign assessment, how long should you wait prior to performing vital checks?

A

at least 15 minutes

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6
Q

Body _____ = Heat _______- _____ lost

A

Temperature
Produced
heat

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7
Q

What keeps the body’s core temperature or temperature of deep tissues relatively constant?

A

Temperature-control mechanisms

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8
Q

Because surface temperatures fluctuatate, the acceptable temperature of human beings ranges from?

A

96.8 - 100.4 degrees F (36-38 degrees C)

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9
Q

Temperature control mechanisms of human beings maintain relatively ______ core temperatures. Core temp is _____ reliable than surface temperature.

A

constant

more

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10
Q

What 4 factors contribute to body temperature regulation?

A
  1. Neural and vascular control
  2. Heat production
  3. Heat loss
  4. Behavioral control
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11
Q

What controls the temperature setpoint?

A

Hypothalamus via:

  1. Vasodilation & Sweating (if temperature increased)
  2. Shivering & Vasoconstriction (if temperature decreased)
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12
Q

What happens with disease or trauma to the hypothalamus or spinal cord?

A

body’s ability to control body temperature is decreased.

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13
Q

How is body heat produced?

A

as a by-product of metabolism

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14
Q

______ ______ rate is heat produced by body at rest

A

Basal Metabolic Rate

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15
Q

Name 3 mechanisms besides BMR that contribute to heat production.

A
  1. Muscular activity
  2. Shivering
  3. Non-shivering Thermogenesis (neonates- brown fat)
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16
Q

What are 4 modes of heat loss?

A
  1. Radiation
  2. Conduction
  3. Convection
  4. Evaporation
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17
Q

What is Diaphoresis?

A

Diaphoresis- visual perspiration on forehead & upper thorax reduces body temperature

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18
Q

What is “Behavioral Control” with respect to body temperature regulation?

A

contributing to control of body temperature thru behavior. Depends on degree of temp extreme; persons comfort in environment; thought processes and ability to remove clothing

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19
Q

Name 5 factors that body temperature.

A
  1. Age
  2. Exercise
  3. Hormone Level
  4. Circadian Rhythms
  5. Stress Environment
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20
Q

Describe issues with the newborn and elderly adult and temperature control.

A
  1. newborns do not have fully develop hypothalamus so temps are erratic and they lose heat to environ
  2. elderly have less SQ fat, decreased sweat gland activity and decreased metabolism.
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21
Q

During exercise, increased carb and fat breakdown exercise ______ heat production

A

increases

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22
Q

Our biological rhythm is tied to the sleep/wake system (Circadian Rhythm). The Parasympathetic system (PNS) kicks in and BP and temp _______.

A

decrease

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23
Q

During a fever, heat loss is unable to keep pace with excess heat production. This results from alteration of hypothalamic set point caused by pyrogens that stimulate the immune system.
WBC production is ________, which _______ growth of bacteria; and _____ viral substances through production of ________.

A

stimulated
suppresses
fights
interferon

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24
Q

Heat stroke results in?

A

giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence and HOT DRY SKIN

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25
Q

The 3 stages of hypothermia are mild, moderate and severe. What temperature ranges are associated with each level?

A

Mild 34-36 C or 93.2-96.8 F
Moderate 30-33 C or 86 – 93.2 F
Severe < 30 C or <86 F

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26
Q

If the body is below 34 C heart/respiratory rate & BP drop. Shivering, loss of memory, depression and poor judgment can also indicate ______.

A

Hypothermia

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27
Q

Does body temp spike more with bacterial or viral infections?

A

bacterial

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28
Q

What is the 1st goal with hypothermia? What other interventions can you perform?

A
  1. prevent further heat loss
  2. gradually warm up the body with warm IV fluids, blankets, drink hot fluids (no caffeine or alcohol), cover head, use heating pads near head
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29
Q

If someone presented with a fever of 104 F and hot dry skin, what immediate diagnosis would you think of?

A

Heat stroke

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30
Q

What are interventions for hyperthermia?

A
  1. Replace fluids preferably orally (IV if necessary)
  2. gradually cool the body down. Cool bath, wraps on forehead
  3. give antipyretic.
  4. need to determine if bacterial source for fever so take blood cultures then figure out which antibiotic to use (assuming not viral infection).
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31
Q

What are 5 areas to perform temperature measurement?

A
  1. Tympanic Membrane
  2. Rectal
  3. Oral
  4. Axilla
  5. Skin
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32
Q

Does the anterior hypothalamus control hot or cold temperature deviations? posterior?

A

anterior: hot
posterior: cold

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33
Q

The ______ is the palpable bounding of the blood flow in the peripheral artery (Stroke volume). The number of beats occurring in 1 minute is your ______ ______.

A

pulse

pulse rate

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34
Q

Cardiac Output =

A

(Cardiac Output=HR x SV)

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35
Q

What is the normal volume of blood pumped in one minute?

A

5 Liters

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36
Q

Would you expect the pulse to be weaker or stronger in foot of the diabetic?

A

weaker (further from head)

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37
Q

The peripheral pulse is commonly measured via the radial and carotid arteries because they are easily _____.

A

palpated

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38
Q

Besides the radial and carotid arteries, what other areas could be used for the peripheral pulse?

A 
Temporal
Brachial
Ulnar
Femoral
Popliteal
Posterior tibial
Dorsalis Pedis
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39
Q

The ______ ______ provides a more accurate assessment of heart rate.

A

Apical pulse

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40
Q

______ and _______ of a pulse reflects volume & pressure of blood ejected against arterial wall with each contraction & condition of vasculature leading to pulse site.

A

Strength and amplitude

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41
Q

When could a doppler be used to find pulse?

A

if pt has edema (pitting), doppler can pick up

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42
Q

What is the normal pulse rate for adults?

infants?

A

Pulse rate
Normal ranges 60-100 adults
infants: 120-160 infants

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43
Q

Name several factors that influence pulse rate.

A

increase: hyperthyroidism, caffeine, exercise decrease: Medications that cause vasodilation, Ca++, hypothermia

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44
Q

Pulse rhythm is described as _____ or _____.

A

regular

dysrythmia

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45
Q

Strengh and equality are measured on a scale of 1-4 and described as bounding, _____ or ____.

A

equal

absent

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46
Q

Pain signifies lack of ______ to tissue

A

oxygen

47
Q

Exercise, Temperature and emotion all _____ temperature.

A

increase

48
Q

Name 4 factors that pulse rate.

A
  1. Drugs
  2. Hemorrhage
  3. Postural Change
  4. Pulmonary Condition
49
Q

Bronchodilators and epinephrine ______ pulse rate.

A

increase

50
Q

How does a hemorrhage affect hear rate?

A

LOSS OF BODY FLUID INITIAL INCREASEs HR IF NO FLUID REPLACEMENT THEN DECREASE HR IF NO INTERVENTION THEN SHOCK

51
Q

What affect do postural changes have on heart rate?

A

ORTHOSTATIC HYPOTENSION RELATED TO ABILTY OF ARTERIES TO DILATE OR RESTRICT. ARTERIES SHOULD CONSTRICT WHEN YOU SIT-UP IF THEY DONT BLOOD POOLS IN LEGS AND BRAIN DOESN’T GET ENOUGH

52
Q

Pulmonary conditions have what affect on heart rate?

A

WILL CREATE PROBLEM INCREASING HR

HEART HAS TO PUMP MORE AND MORE FOR INCREASED BLOOD/O2

53
Q

What attributes should be evaluated during a pulse assessment?

A

Note Rate, Rhythm, Equality and Pulse volume

54
Q

Pulse Volume should be noted as ? (5)

A 
Full 
bounding
Weak 
febrile (high)
thready (faint)
55
Q

When considering signs and symptoms of irregular hear rate, ______ indicates difficulty breathing. Fatigue can _______ HR. Pallor or paleness indcicates, beginning of _____ deprivation to _______.
When checking for Cyanosis check _____ _____, on darker skinned people difficult to see.
Palpitations are an ______ beat. That speeds up and slows down. Syncope or _____ could be vagal response.

A 
dyspnea
elevate
oxygen
tissues
mucus membranes
irregular
fainting
56
Q

Respiration

A

the mechanism the body uses to exchange gases between the atmosphere and the blood and the cells.

57
Q

Respiration involves what 3 processes?

A

ventilation
diffusion
perfusion

58
Q

Respiration involves three processes: _____ (the mechanical movement of gases in and out of the lungs), ________ (the movement of oxygen and carbon dioxide between the alveoli and the red blood cells) and _______ (the distribution of red blood cells to and from the pulmonary capillaries.

A

ventilation
diffusion
perfusion

59
Q

When measuring respiration, check the ______ and _____ of breathing: do during pulse check, count for ___ seconds and multiply by 2. If respiratory issue, count for a full _____. Also check for _____ ___ _____ movements (check that both sides rise and fall _____).

A 
rate 
depth
30
minute
rhythm of ventilatory
evenly
60
Q

What does uneven rhythm of ventilatory movements indicate? (ie, both sides don’t rise and fall evenly)

A

could be collapsed lung.

61
Q

When checking respiratory rate, Observe a full inspiration and _______. Also check nail beds for ______ refill.

A

expiration

capillary

62
Q

While checking respiratory rates, other assessments can be performed. The ______ of respirations is assessed by observing the ______ of excursion or movement in the chest wall and regularity of respiratory rhythm (symmetry of lungs).
May also see associated diaphragmatic movement (belly breathing), children belly breath, in adult this is abnormal but more common in _____. _______ movements may be described as deep, normal, or shallow. deep: when someone sleeping, has a chest tube or rib damage, expect _____.
Patients who have had chest surgery, trauma, tubes or asthma attack may have apparent use of intercostal or accessory muscles and _____.

A 
depth
degree
ventilatory
shallow breaths
retractions
63
Q

Name 9 factors that influence the character of respiration.

A
  1. Exercise
  2. Acute Pain
  3. Anxiety
  4. Smoking
  5. Body Position
  6. Medications
  7. Neurologic Injury
  8. Hemoglobin Function
64
Q
  1. How is arterial oxygen saturation measured?
  2. What distinguishes between oxygenated and de-oxygenated hemoglobin molecules?
  3. What is accuracy dependent upon during measurment?
A
  1. pulse oximeter permits the indirect measurement of oxygen saturation.
  2. a light sensor
  3. light transmission & adequate arterial pulsations.
65
Q
  1. ______ is the force exerted on the walls of an artery created by the pulsing blood under pressure from the heart.
  2. _____ is the peak of maximum pressure when ejection occurs is the systolic blood pressure.
  3. _____ is when the heart relaxes, the blood remaining in the arteries exerts a minimum pressure.
  4. The standard unit for measuring blood pressures is _______.
  5. The difference between systolic and diastolic pressure is the ______.
A
  1. Blood pressure
  2. Systolic
  3. Diastolic
  4. millimeters of mercury (mm Hg).
  5. pulse pressure
66
Q

Blood pressure reflects the interrelationships of ______ _____, peripheral _____ ______ , blood volume, blood _____, and artery _______.

A

cardiac output
vascular resistance
viscousity
elasticity

67
Q

What is the adult blood pressure range for: normal
prehypertension
stage 1 hypertension
stage 2 hypertension

A

Normal < 120 / <80
Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension ≥160 or ≥100

68
Q

Name 9 factors that influence blood pressure.

A
  1. Age (increases with age)
  2. Stress (elevates BP)
  3. Ethnicity: Ex. African Amer have hypertension while asians have low BP
  4. metabolism
  5. Gender
  6. Daily variation (i.e.situational) lowest middle of night
  7. Medications
    8 Activity and Weight
  8. Smoking
69
Q

how does smoking affect BP?

A

Increases BP due to affects on arterial elasticity.

70
Q 
Hypotension is considered present when the systolic blood pressure falls to \_\_\_ mm Hg or below.
Orthostatic hypotension (postural hypotension)- symptomatic drop in BP with change in \_\_\_\_\_\_\_. This is due to decreased systemic \_\_\_\_\_\_\_,  \_\_\_\_\_ blood volume, anemia, dehydration.
A

90
posture
resistance
low

71
Q

Blood Pressure meaurement is an Indirect measurement based on basic principles of pressure.Blood flows freely through ______ until inflated cuff exerts pressure and causes artery to ______.
When cuff pressure is released and blood flow returns = ______ BP
When sound disappears = ________ BP
Karotkoff signs: the different sounds heard during blood pressure measurement.

A

arteries
collapse
systolic
diastolic

72
Q

During pain assessment what does PQRSTU stand for?

A 
Provocative or Palliative: subjective
Quality or Quantity 
Region or Radiation
Severity Scale
Timing
Understand Patients perception of the Problem
73
Q

What is the minimum interval for pain assessment?

A

Assess pt w/ pain at least every 4 hours and medicate for pain reported from patient.

74
Q

What is the Wong-Baker scale?

A

Faces indicating pain score on level of 0-5

75
Q

Blood pressure reflects the interrelationships of ______ _____, peripheral _____ ______ , blood volume, blood _____, and artery _______.

A

cardiac output
vascular resistance
viscousity
elasticity

76
Q

What is the adult blood pressure range for: normal
prehypertension
stage 1 hypertension
stage 2 hypertension

A

Normal < 120 / <80
Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension ≥160 or ≥100

77
Q

Name 9 factors that influence blood pressure.

A
  1. Age
  2. Stress (elevates BP)
  3. Ethnicity: Ex. African Amer have hypertension while asians have low BP
  4. metabolism
  5. Gender
  6. Daily variation (i.e.situational)
  7. Medications
    8 Activity and Weight
  8. Smoking
78
Q

how does smoking affect BP?

A

Increases BP due to affects on arterial elasticity.

79
Q 
Hypotension is considered present when the systolic blood pressure falls to \_\_\_ mm Hg or below.
Orthostatic hypotension (postural hypotension)- symptomatic drop in BP with change in \_\_\_\_\_\_\_. This is due to decreased systemic \_\_\_\_\_\_\_,  \_\_\_\_\_ blood volume, anemia, dehydration.
A

90
posture
resistance
low

80
Q

Blood Pressure meaurement is an Indirect measurement based on basic principles of pressure.Blood flows freely through ______ until inflated cuff exerts pressure and causes artery to ______.
When cuff pressure is released and blood flow returns = ______ BP
When sound disappears = ________ BP
Karotkoff signs: the different sounds heard during blood pressure measurement.

A

arteries
collapse
systolic
diastolic

81
Q

During pain assessment what does PQRSTU stand for?

A 
Provocative or Palliative: subjective
Quality or Quantity 
Region or Radiation
Severity Scale
Timing
Understand Patients perception of the Problem
82
Q

What is the minimum interval for pain assessment?

A

Assess pt w/ pain at least every 4 hours and medicate for pain reported from patient.

83
Q

What is the Wong-Baker scale?

A

Faces indicating pain score on level of 0-5

84
Q 
A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 pounds. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy?
A.	Temperature: 37° C (98.6° F)
B.	Radial pulse: 112
C.	Respiratory rate: 24
D.	Oxygen saturation: 96%
E.	Blood pressure: 134/78
A

D. Oxygen saturation: 96%

85
Q

The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
B. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72
C. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84
D. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

A

A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%

86
Q 
A 56-year-old patient with diabetes admitted for community acquired pneumonia has a temperature of 38.2° C (100.8° F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? (Select all that apply.)
A.	Heart rate
B.	Presence of diaphoresis
C.	Smoking history
D.	Respiratory rate
E.	Recent bowel movement
F.	Blood pressure in right arm
G.	Patient's normal temperature
H.	Blood pressure in distal extremity
A

A. Heart rate
B. Presence of diaphoresis
D. Respiratory rate
G. Patient’s normal temperature

87
Q

A 55-year-old widowed patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient’s blood pressure and temperature?
A. Right antecubital and tympanic membrane
B. Right popliteal and right axillae
C. Left antecubital and oral
D. Left popliteal and temporal artery

A

B. Right popliteal and right axillae

88
Q 
A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions?
A.	Activity order
B.	Medication list
C.	Baseline vital signs
D.	Patient's perception of dyspnea
A

C. Baseline vital signs

89
Q 
During a patient's routine annual physical, she tells you that she has noted that her heart feels like it's "racing," usually in the later morning, early afternoon, or just before she goes to bed. Her radial pulse rate is 68 beats/min and regular; her blood pressure is 134/82 mm Hg. What additional information is helpful in evaluating the patient's racing heart? (Select all that apply.)
A.	Dietary habits
B.	Medication list
C.	Exercise regimen
D.	Age, weight, and height
A

A. Dietary habits

B. Medication list

90
Q

When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is ____ than it really is; you will get a false-_____ reading.

A

higher

high

91
Q 
You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff?
A.	96/40 mm Hg
B.	110/66 mm Hg
C.	130/70 mm Hg
D.	156/82 mm Hg
A

D. 156/82 mm Hg

92
Q

As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. Your best reply is:
A. Nail polish attracts microorganisms and contaminates the finger sensor.
B. Nail polish increases oxygen saturation.
C. Nail polish interferes with sensor function.
D. Nail polish creates excessive heat in sensor probe.

A

C. Nail polish interferes with sensor function.

93
Q

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements?
A. Usual range of circadian rhythm measurements
B. Sustained fever pattern
C. Intermittent fever pattern
D. Resolving fever pattern

A

C. Intermittent fever pattern

94
Q

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention?
A. Request that the nursing assistant repeat the pulse check
B. Call for a stat electrocardiogram (ECG)
C. Assess the patient’s apical pulse and evidence of a pulse deficit
D. Prepare to administer cardiac-stimulating medications

A

C. Assess the patient’s apical pulse and evidence of a pulse deficit

95
Q

Which of the following patients is most at risk for tachycardia?
A. A healthy professional tennis player
B. A patient admitted with hypothermia
C. A patient with a fever of 39.4° C (103° F)
D. A 90-year-old male taking beta blockers

A

C. A patient with a fever of 39.4° C (103° F)

96
Q

Would the following condition be associated with low or high heart rate?

  1. Patients with a fever
  2. A healthy athlete has a low heart rate because of conditioning.
  3. A patient with hypothermia
  4. A patient taking Beta-blockers reduce heart rate.
A
  1. Patients with a fever have a high heart rate.
  2. A healthy athlete has a low heart rate because of conditioning.
  3. hypothermia slows the heart rate.
  4. Beta-blockers reduce heart rate.
97
Q

Which of the following patients is at most risk for tachypnea? (Select all that apply.)
A. Patient just admitted with four rib fractures
B. Woman who is 9 months’ pregnant
C. Adult who has consumed alcoholic beverages
D. Adolescent awaking from sleep

A

A. Patient just admitted with four rib fractures
B. Woman who is 9 months’ pregnant

(Rib fractures would cause splinting and pain to increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths.)

98
Q 
The following blood pressures, taken 6 months apart, were recorded from patients screened by the nurse at the assisted living facility. Which patient should be referred to the healthcare provider for hypertension evaluation?
A.	120/80, 118/78, 124/82
B.	128/84, 124/86, 128/88
C.	148/82, 148/78, 134/86
D.	154/78, 118/76, 126/84
A

C. 148/82, 148/78, 134/86

The definition of hypertension requires two elevated blood pressure measurements in a row. All of the other choices describe prehypertension.

99
Q

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement should you reassess? (Select all that apply.)
A. Right arm BP: 120/80
B. Radial pulse rate: 72 and irregular
C. Temporal temperature: 37.4° C (99.3° F)
D. Respiratory rate: 28
E. Oxygen saturation: 99%

A

B. Radial pulse rate: 72 and irregular
D. Respiratory rate: 28
E. Oxygen saturation: 99%
An irregular pulse may be the result of a complication of heart disease and requires the assessment of the apical rate. A respiratory rate of 28 is abnormal, yet the oxygen saturation is normal. Both oxygen saturation and respiratory rate would be expected to be outside of the acceptable range.

100
Q

A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The licensed practical nurse (LPN) reports that she had difficulty obtaining the patient’s heart rate from his right radial pulse. What is your best response?
A. Assess the patient’s apical pulse to obtain the heart rate.
B. Obtain the heart rate from right and left radial sites.
C. Obtain the heart rate using the oximeter probe.
D. Perform a complete assessment of all pulses.

A

D. Perform a complete assessment of all pulses.

When an LPN reports that one pulse is difficult to obtain, first you need to assess the patient yourself and compare the quality of all pulses.

101
Q

Compare average oral, tympanic, rectal temperature. (coolest is axillary then oral/tympanic then rectal)

A

Average oral/tympanic: 37° C (98.6° F)
Average rectal: 37.5° C (99.5° F)
Average axillary: 36.5° C (97.7° F)

102
Q

Patterns of Fever

  1. _______ A constant body temperature continuously above 38° C (100.4° F) that has little fluctuation.
  2. ________ Fever spikes interspersed with usual temperature levels (Temperature returns to acceptable value at least once in 24 hours.)
  3. ______ Fever spikes and falls without a return to normal temperature levels.
  4. _______ Periods of febrile episodes and periods with acceptable temperature values (Febrile episodes and periods of normothermia are often longer than 24 hours.)
A
  1. Sustained
  2. Intermittent
  3. Remittent
  4. Relapsing
103
Q

Patients at risk for ______ include the very young or very old and those who have cardiovascular disease, hypothyroidism, diabetes, or alcoholism.

A

heatstroke

104
Q

With _______, Vital signs reveal a body temperature sometimes as high as 45° C (113° F), with an increase in heart rate (HR) and lowering of BP. The most important sign is hot, dry skin.

A

heatstroke

105
Q

Bradypnea

A

Rate of breathing is regular but abnormally slow (less than 12 breaths/min).

106
Q

Tachypnea

A

Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min).

107
Q

Hyperpnea

A

Respirations are labored, increased in depth, and increased in rate (greater than 20 breaths/min) (occurs normally during exercise).

108
Q

Apnea

A

Respirations cease for several seconds. Persistent cessation results in respiratory arrest.

109
Q

Hyperventilation

Hypoventilation

A

Hyperventilation: Rate and depth of respirations increase. Hypocarbia sometimes occurs.

Hypoventilation: Respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs.

110
Q

Cheyne-Stokes respiration

A

Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses; breathing slows and becomes shallow, climaxing in apnea before respiration resumes.

111
Q

Kussmaul’s respiration

A

Respirations are abnormally deep, regular, and increased in rate.

112
Q

Biot’s respiration

A

Respirations are abnormally shallow for two to three breaths followed by irregular period of apnea.

113
Q

How would the following impact BP measurement?

  1. Bladder or cuff too wide, narrow or too short
  2. Cuff wrapped too loosely or unevenly
  3. inflating or Deflating cuff too slowly
  4. Deflating cuff too quickly
  5. Arm below heart level
  6. Arm above heart level
  7. Arm not supported
A
  1. False-high reading
  2. false-high
  3. False-high diastolic
  4. False-low systolic and false-high diastolic reading
  5. false-low
  6. false-high
  7. false-high
114
Q

Systolic pressure in the legs is usually _______ by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is the same.

A

higher

N200 (9 decks)

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