Vital Signs and Physical Assessment Flashcards
This organ controls the body’s temperature by sensing a change in the body’s “set point”.
Hypothalamus
The heat produced by the body at rest.
Basal metabolic rate
This is a compensatory mechanism for when the body senses heat loss, which causes skeletal muscle movement to generate heat production.
Shivering
How do infants conserve heat when their shivering mechanism is not fully functional?
Infants have a limited amount of vascular brown tissue at birth which is metabolized to generate heat.
What temperature changes happen during the menstrual cycle?
Temperature decreases slightly just before ovulation but may increase to 1° F above normal during ovulation.
What should a nurse who is about to take temperature via the oral route consider if a patient has recently consumed hot liquids such as coffe?
Wait 15 to 30 minutes before taking the temperature orally
Give at least three contraindications of the rectal route of temperature taking.
Cardiac client
Client who has undergone rectal surgery
Client with diarrhea, fecal impaction, or rectal bleeding
A type of fever characterized by spikes in temperatures mixed with a least one episode of normal temperature within a 24 hour period.
Intermittent Fever
A fever that spikes and falls but never reaches normal temperature levels.
Remittent Fever
Where would you place a thermometer probe if reading a temperature via the temporal artery?
Flushed against the skin and slid across the forehead, or placed in the area of temporal artery and held in place.
If client is diaphoretic, the probe may be placed on the neck, just behind the earlobe.
Where would you palpate the brachial pulse?
Above the elbow at the antecubital fossa, between the biceps and triceps muscles
Where would you locate the apical pulse?
Left midclavicular line, 5th intercostal space
Give the interpretation of the following pulse gradings:
4 +
3 +
2 +
1 +
0
4 + = strong and bounding
3 + = full pulse, increased
2 + = normal, easily palpable
1 + = weak, barely palpable
0 = absent, not palpable
Where would you locate the dorsalis pedis pulse?
On the top of the foot, in live with the groove between the extensor tendons of the great and first toes
A nurse notes that the radial pulse is less than the apical pulse. This condition is called?
Pulse Deficit.
This indicates a lack of peripheral perfusion and can also be an indication of cardiac dysrythmias.
A nurse teaching the patient to monitor their own heart rate would teach them to locate which peripheral pulse site?
Radial Pulse. This is the most commonly used because it is the most convenient.
The most accurate pulse reading is taken here, and this should be assessed along with the radial pulse if taking the pulse rate for the first time.
Apical Pulse
This pulse site is used when the patient’s condition suddenly worsens and cardiac output declines significantly.
Carotid Pulse
When taking blood pressure and the brachial artery is not accessible, where would the nurse:
Wrap the cuff?
Place the stethoscope?
The leg may be used if brachial artery is not accessible. The cuff is wrapped around the thigh and the stethoscope is placed over the popliteal artery.
What is the effect on blood pressure:
Taking blood pressure reading when person is anxious or angry.
False high due to sympathetic nervous system stimulation
What is the effect on blood pressure:
Arm placed above the level of the heart
False low because it eliminates effect of hydrostatic pressure
What is the effect on blood pressure:
Cuff too narrow or small for extremity
False high because excessive pressure is needed to occlude the brachial artery
What is the effect on blood pressure:
Cuff wrap too loose or uneven
False high because excessive pressure is needed to occlude the brachial artery
How would you position a client for examination of the female genitalia?
Lithotomy
