NursingTest 4

Question 1

What are the 6 vital signs that are taken to give some indication of a person’s state of health

Answer 1

temperature
pulse
respiration
blood pressure
pain level
oxygen saturation

Question 2

define metabolism

Answer 2

cellular chemical reactions in the body

Question 3

what causes a fever and what are agents that cause fever

Answer 3

when metabolism increases, more heat is produced

pyrogens are agents that cause fever

Question 4

what is acts as a thermostat and controls body temperature by a feedback mechanism

Answer 4

hypothalamus, located btw the cerebral hemispheres

Question 5

when the body heat rises above normal, the hypothalamus sends out a signal through the nervous system that cause ___ ___ and ___

Answer 5

vasodilation
sweating
inhibition of heat production

Question 6

heat loss occurs through what four ways

Answer 6

radiation
conduction
convection
evaporation

Question 7

define pyrexia

Answer 7

fever
occurs when normal mechanisms of the body cannot keep up with the excessive heat production and body temperature rises
Temp rises above 100.2 or 37.9 C

Question 8

define stroke volume

Answer 8

the volume of blood pushed into the aorta per heartbeat

Question 9

define systolic pressure

Answer 9

the maximum pressure exerted o the artery during left ventricular contraction

Question 10

define diastolic pressure

Answer 10

the lower pressure exerted on the artery when the heart is at rest btw contractions

Question 11

What is the range of normal body temperature and what is the average temp of a young healthy adult

Answer 11

97. 5-99.5 AND 36.4-37.5

98. 6 OR 37

Question 12

what temperature usually indicates a fever

Answer 12

100.2 OR 37.9

Question 13

during pregnancy, how different in the average temp and why

Answer 13

may stay at a high normal because of an increase in the patients metabolic rate

Question 14

what are the stages of fever

Answer 14

onset=maybe be gradual/suddenly
febrile=body temp rises
defervescence=lowering of body temp

Question 15

fevers are classified into what four categories

Answer 15

constant=continuously elevated
intermittent=temp alternates rising and falling
remittent=temp falls in morning, then rises later on in day
relapsing=temp falls to normal and then rises again in a repeated pattern

Question 16

what are some common pulse points

Answer 16

radial
temporal
carotid
femoral
apical, over the apex
popliteal
pedal posterior tibial

Question 17

the apical, rather than the radial pulse, is taken on children younger than ____

Answer 17

2 years

Question 18

what are the average pulse rates for:
normal pulse range
some althletes
adult male
adult female
child age 5
child age 1
newborn

Answer 18

normal pulse range=60-100
some althletes=45-60
adult male=72
adult female76-80
child age 5=95
child age 1=110
newborn=120-160

Question 19

what are some factors that affect pulse rate

Answer 19

age
body build and size
blood pressure
drugs
emotions
blood loss
exercise
increased body temp
pain

Question 20

while taking the pulse, what else should be noted

Answer 20

rate
rhythm
volume

Question 21

What are the normal range of respirations for the age groups:
elderly
healthy adult
adolescent
child age 3
child age 1
newborn

Answer 21

elderly=16-20
healthy adult=12-20
adolescent=16-20
child age 3=20-30
child age 1=20-40
newborn=30-80

Question 22

what are some symptoms of hypoxia that may be noted as a result of low oxygen supply in the blood

Answer 22

apprehension and restlessness
confusion, dizziness
change in the level of consciousness
cyanosis particularly around the mouth and in nail beds

Question 23

define eupnea

Answer 23

normal, relaxed breathing pattern

effortless, evenly spaced, regular, automatic

Question 24

define dyspnea

Answer 24

difficult and labored breathing

Question 25

define tachypnea

Answer 25

increased or rapid breathing

Question 26

define bradypnea

Answer 26

slow and shallow breathing

Question 27

define hyperventilation

Answer 27

a pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled causing blood level of carbon dioxide to fall

Question 28

define kussmaul respirations

Answer 28

increased rate and depth with panting and long, grunting exhalation seen in pt with diabetic acidosis and renal failure

Question 29

define biot respirations

Answer 29

shallow for two or three breaths with a period of variable apnea (absence of breathing) occur in pt with increased intracranial pressure

Question 30

define Cheyne-Stokes respirations

Answer 30

- pattern of dyspnea followed by a short period of apnea - respirations are faster and deeper, then slower and are followed by a period of no breathing - pt who is critically ill, brain conditions, heart or kidney failure, drug overdose

Question 31

define crackles

Answer 31

abnormal, nonmusical sound heard on auscultation | also called rales

Question 32

define rhonchi

Answer 32

continuous dry, rattling sounds caused by partial obstruction

Question 33

define stertor

Answer 33

snoring sound produced when pt is unable to cough up secretion from the trachea or bronchi

Question 34

define stridor

Answer 34

crowing sound on inspiration caused by obstruction of the upper air passages as occurs in croup or laryngitis

Question 35

define wheeze

Answer 35

whistling sound of air forced pas a partial obstruction | found in asthma or emphysema

Question 36

what is pulse pressure

Answer 36

the difference between systolic and diastolic pressure | EX: 120/80=120-80=40

Question 37

why should a pt not cross their legs when a blood pressure is being taken

Answer 37

it cause an elevation in systolic and diastolic pressure

Question 38

prolonged hypertension can cause permament damage to the __, __, __, and __ of the eye.

Answer 38

brain kidneys heart retina

Question 39

what are some causes of shock

Answer 39

``` hemorrhage vomitting diarrhea burns myocardial infarction ```

Question 40

what are some signs of shock

Answer 40

``` decrease in BP increase in HR cold and clammy skin dizziness blurred vision apprehension ```

Question 41

pain assessment must include

Answer 41

``` location intensity character frequency duration ```

Question 42

temperature measurement through ___ is the closest to core body temperature

Answer 42

tympanic

Question 43

a CNA reporst to the nurse that the T of a pt who is 1st day postoperative is 100.2F. Which action should the nurse take?

Answer 43

tell CNA to take T again in 2 hours

Question 44

T greater than 105.8 should be treated promptly to reduce the fever because of what?

Answer 44

potential damage to the cells of the CNS

Question 45

a newly admitted pt has a respiratory rate of 16/minute. which action should the nurse take

Answer 45

note the rate on the chart, respiratory rate is normal

Question 46

a pt who makes harsh high sounds on inspiration has what kind of respiratory condition

Answer 46

stridor

Question 47

what are the physical examination techniques

Answer 47

``` inspection and observation palpate percussion auscultation olfaction ```

Question 48

define lordosis

Answer 48

exaggerated lumbar curve

Question 49

define kyphosis

Answer 49

increased curve in the thoracic area

Question 50

define scoliosis

Answer 50

pronounced lateral curvature of the spine

Question 51

when documenting pupils, what does PERRLA mean

Answer 51

``` pupils equal round reactive light accommodation ```

Question 52

define nystagmus

Answer 52

jerky movements

Question 53

in Glasgow coma scale, what is highest possible score, and what indicates a coma

Answer 53

15 | 7

Question 54

when assessing a complaint of bloating and gas, you would assess for air within the intestines by ___

Answer 54

percussion

Question 55

wet, crinkly sounds heard on auscultation of the lungs are referred to as _____ and indicate ___

Answer 55

crackles | moisture in the lungs