Unir X - Vital Signs Flashcards
Define core temperature
It is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity.
Define normal body temperature
It is a range of temperatures
What is the surface temperature
It is the temperature of the skin, the subcutaneous tissue, and fat
What are the factors that affect the body’s heat production? Briefly discuss each one.
1) BMR: The basal metabolic rate (BMR) is the rate of energy utilization in the body required to maintain essential activities such as breathing.
2) Muscle activity: muscle activity, including shivering, increases the metabolic rate.
3) Thryoxine output: Increased thyroxine output increases the rate of cellular metabolism throughout the body
4) Epinephrine, norepinephrine, and sympathetic stimulation/stress response: The hormones immediately increase the rate of metabolism in many body tissues.
5) Fever: Fever increases the cellular metabolism and thus increases the body’s temperature
Berman Textbook - Chapter 16
The client’s temperature at 8:00 am using an oral electronic thermometer is 36.1ºC (97.2ºF). If the respiration, pulse, and blood pressure are within the normal range, what would the nurse do next?
A. Wait 15 minutes and retake it
B. Check what the client’s temperature was last time
C. Retake it using a different thermometer
D. Document the temperature
B. Check what the client’s temperature was last time
Rationale:
Although the temperature is lower than expected for a morning temperature, it would be best to determine the client’s previous temperature range because it ay be normal for this client. Only if the temperature is out of range is it necessary to retake the reading using a different thermometer (option C) and there would be no need to wait 15 minutes (option A). The temperature would be documented after determining accuracy of the reading (Option D)
Berman Textbook - Chapter 16
Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than the radial pulse?
A. A client in shock
B. A client whose pulse changes with body position changes
C. A client with arrhythmia
D. A client who underwent surgery less than 24 hours ago.
C. A client with arrhythmia
Rationale:
The apical pulse rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would reveal only the heart rate and suggest an arrhythmia. For clients in shock, the carotid or femoral pulse (Option A). The orthostatic heart rate (Option B). The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses (Option D)
Berman Textbook - Chapter 16
When nurse enters the room to measure vital signs in preparing the client for a diagnostic test, the client is on the phone. What technique should the nurse use to determine the respiratory rate?
A. Count the respirations during conversational pauses.
B. Ask the client to end the phone call now and resume it at a later time.
C. Wait at the client’s bedside until the phone call is completed and then count respirations.
D. Since there is no evidence of distress or urgency, defer the measurement.
D. Since there is no evidence of distress or urgency, defer the measurement.
Rationale:
Since the client’s needs are always considered first, the measurement should be delayed until the phone call is completed. (Option A); Respirations should be measured for 30 seconds to 1 minute and are effected by talking, so measurements whil on the phone would be inaccurate. Option B; There needs to be an important reason for interrupting the client and since this client is not in distress no truly important exists. Option C; It is inappropriate to wait and listen to the client’s conversation.
Berman Textbook - Chapter 16
For a client with a previous blood pressure of 138/74 and pulse of 64, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?
A. 10-20 seconds
B. 30-45 seconds
C. 1-1.5 minutes
D. 3-3.5 minutes
B. 30-45 seconds
Rationale:
If the cuff is inflated to about 30 mm Hg over previous systolic pressure, that would be 168. To ensure that the diastolic has been determined, the cuff should be released slowly until the mid 60s mm Hg (and then completely) for someone with a rate of 2 to 3 min per second. Thus, a range of 90 mm Hg will require 30 to 45 seconds.
Berman Textbook - Chapter 16
It would be appropriate for the nurse to delegate measure of vital signs to a UAP for which of the following clients?
A. A client being prepared for elective facial surgery with a history of stable hypertension.
B. A client receiving a blood transfusion with a history of transfusion reactions.
C. A client recently started on a new antiarrhythmic agent.
D. A client who has been repeatedly admitted secondary to asthma exacerbations
A. A client being prepared for elective facial surgery with a history of stable hypertension.
Rationale:
Vital signs measurement may be delegated UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements. The client receiving blood (Option B) and the client with asthma (Option D) are not considered stable. In addition, the UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client with the client newly started on antiarrhythmic medication (Option C)
Berman Textbook - Chapter 16
An 85-year old client has had a stroke resulting in right-sided facial drooping, difficult swallowing, and is unable to move or maintain position independently. The nurse determines that which of the following are appropriate sites for measuring body temperature? Select all that apply.
A. Oral B. Rectal C. Axillary D. Tympanic E. Temporal artery
C. Axillary
D. Tympanic
E. Temporal Artery
Rationale:
For this client, the nurse could take an axillary, tympanic or temporal artery temperature. Due to the facial drooping and difficulty swallowing, the oral route is not recommended. Although the rectal route could be used, it would require unnecessary moving and positioning of a client who cannot assist, would expose the client to potential embarrassment, and would not provide a significant advantage over the other routes.
Berman Textbook - Chapter 16
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following:
A. Bounding radial pulse
B. Irregular apical pulse
C. Carotid pulse stronger on the left side than the right
D. Absent posterior tibial and pedal pulses
D. Absent posterior tibial and pedal pulses
Rationale:
The posterior tibial and pedal pulses int eh foot are considered peripheral and at least one of them should be palpable in normal individuals. Option A: A bounding radial pulse is more indicative that perfusion exists. Option B and C: Apical and carotid pulses are central and not peripheral
Berman Textbook - Chapter 16
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following while the client was walking?
A. Shallow respirations
B. Wheezing
C. Shortness of breath
D. Coughing up blood
C. Shortness of breath
Rationale:
Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed. Shallow respirations (Option A) are seen in tachypnea (rapid breathing). Wheezing (Option B) is a high-pitched breathing sound that may or may not occur with dyspnea. The medical term for coughing up blood is hemoptysis (Option D) and is unrelated to dyspnea.
ATI - VS Module
You are assessing a patient’s vital signs. The patient has a temperature of 102º F (39º C). Which of the following do you expect to find?
A. An elevated pulse rate
B. A decreased blood pressure
C. An elevated blood pressure
D. A decreased pulse rate
A. An elevated pulse rate
Rationale:
A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.
ATI - VS Module
The difference between a patient’s systolic and diastolic blood pressure is called
A. an ausculatory gap.
B. the pulse pressure.
C. a diurnal variation.
D. the pulse deficit.
B. the pulse pressure.
Rationale:
The difference between the systolic and diastolic pressures is the pulse pressure; if the patient’s blood pressure is 130/85 mm Hg, the pulse pressure is 45/min. Pulse pressure can be a predictor of heart problems, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atheroscerlosis.
ATI - VS Module
When taking a patient’s blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase?
A. It corresponds to the patient’s systolic pressure.
B. You need it to record the second diastolic pressure.
C. It is the loudest of the Korotkoff sounds.
D. You might not hear the fifth Korotkoff sound.
D. You might not hear the fifth Korotkoff sound.
Rationale:
Most clinicians the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient’s diastolic blood pressure. However, with some patients, there is not distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic pressure.
ATI - VS Module
When auscultating the patient’s apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the
A. atria contract vigorously.
B. ventricular walls vibrate.
C. semilunar valves close.
D. mitral valve snaps open.
C. semilunar valves close.
Rationale:
The second heart sound, S2, is generated by the closure of the semilunar valves (the aortic and pulmonic valves) and signals the start of diastole. S2 is the “dub” heard in the normal “lub-dub” sound.
ATI - VS Module
You are measuring a patient’s temperature orally. You place the covered probe
A. in the posterior lingual pocket lateral to the midline.
B. so that it rests on the lower lingual frenulum.
C. centrally on top of the patient’s tongue.
D. under the tongue just beyond the patient’s teeth.
A. in the posterior lingual pocket lateral to the midline.
Rationale:
The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe “sideways” into the back of the area under the tongue on the left or the right will access this area
ATI - VS Module
You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient’s respiration, you
A. instruct the patient to breathe in and to exhale out as he would normally.
B. make the patient physically comfortable before beginning the assessment
C. determine if the patient has a history of any chronic respiratory problems.
D. observe the patient’s chest movements while appearing to assess his pulse.
D. observe the patient’s chest movements while appearing to assess his pulse.
Rationale:
You are most likely to observe the true respiratory pattern (rate, rhythm and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed it is common for them to alter their respiratory pattern either voluntarily or involuntarily.
ATI - VS Module
When taking an adult patient’s temperature rectally, it is important to
A. rotate the probe gently if you encounter any resistance.
B. insert the probe so that you are aiming at the patient’s pelvic area.
C. dip the probe about an inch to an inch and a half into a tube of lubricant.
D. insert the probe about an inch and a half into the patient’s anus.
D. insert the probe about an inch and a half into the patient’s anus.
Rationale:
An insertion depth of 1.5 inches (3.5 cm) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to measure heat maximally and accurately.
ATI - VS Module
To auscultate a patient’s apical pulse accurately, you position the bell or the diaphragm of your stethoscope over the point of maximal impulse, which is located
A. at the right midclavicular line.
B. over the Angle of Louis.
C. at the fifth intercostal space at the left midclavicular line.
D. over the suprasternal notch.
C. at the fifth intercostal space at the left midclavicular line.
Rationale:
To the locate the PMI, first locate the angle of Louis - a bony prominence just below the suprasternal notch. Slide your fingers down each side of the angle of the Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.
ATI - VS Module
When preparing to measure the vital signs of a patietn, you should recognize that which of the following will affect the methods that you will use? (Select all that apply)
A. The patient is 60 lbs overweight.
B. The patient has been nauseated for 2 days.
C. The patient is reporting a “stuffy” nose.
D. The patient has been fasting for blood tests.
E. The patient is taking digoxin (Lanoxin).
F. The patient had a mastectomy 2 years ago.
A. The patient is 60 lbs overweight.
C. The patient is reporting a “stuffy” nose.
E. The patient is taking digoxin (Lanoxin).
F. The patient had a mastectomy 2 years ago.
Rationale:
Nausea, while uncomfortable and possibly a symptom of gastrointestinal pathology, has no direct effect on how you would assess vital signs.
While the recent ingestion of foods of extreme temperature (hot or cold) can affect the accuracy of a temperature measured orally, the lack of food has no direct bearing on how you would check the patient’s vital signs.
ATI - VS Module
You have assessed a 45-year-old patient’s vital signs. Which of the following assessment values requires immediate attention?
A. An oral temperature of 100º F (37.8º C)
B. A blood pressure of 148/88l mm Hg
C. A respiratory rate of 30/min
D. A radial pulse rate of 45 beats per 30 seconds
C. A respiratory rate of 30/min
Rationale:
A respiratory rate of 30/min is above the normal range and indicates a respiratory problem that requires immediate attention. An adult breathing at that rate might be experiencing shortness of breath or dyspnea, and without intervention, this could become a life-threatening situation.
ATI - VS Module
The best way to determine the depth of a patient’s respiration is to
A. observe the degree of the chest-wall movement during inspiration and expiration.
B. count how many breathing cycles you observe per minute.
C. notice whether or not expiration takes longer than inspiration.
D. measure the precise amount of air the patient takes in and breathes out.
A. observe the degree of the chest-wall movement during inspiration and expiration.
Rationale:
You determine the depth of respiration subjectively by evaluating how much chest-wall movement you can observe. The movement is generated by the movements of the diaphragm and intercostal muscles at the patient breaths. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.
ATI - VS Module
The most important factor in measuring blood pressure accurately is
A. obtaining the reading in the early morning.
B. using a cuff of the appropriate size for the patient.
C. making sure the patient is comfortable and relaxed.
D. removing the clothing from the arm before applying the cuff.
B. using a cuff of the appropriate size for the patient.
Rationale:
Using the wrong cuff size for the patient will result in an erroneous reading. A cuff that is too small will result in a reading that is falsely high while a cuff that is too big will record a false low. One way to select a cuff is to make sure the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder (inside the cuff) should surround 80% of the arm circumference.
ATI - VS Module
When assessing a patient’s respiration, it is recommended that the patient
A. lie flat in bed with his/her head on a pillow.
B. have the head of the bed elevated 45 to 60º.
C. continue to go about his/her usual activities.
D. take several deep breaths prior to assessment.
B. have the head of the bed elevated 45 to 60º.
Rationale:
This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase the respiratory rate.
