Vital Signs (Quiz 1)

Question 1

What are the 4 vital signs

Answer 1

1) Temperature
2) Pulse rate & rhythm
3) Respiration rate
4) Blood pressure

Question 2

What is normal core temperature?

Answer 2

In degrees Fahrenheit

97.0 - 99.5

Question 3

How do oral and tympanic temperatures differ from core temperature?

Answer 3

Approximately 1 degree Fahrenheit lower

Question 4

How do temporal artery and rectal temperatures differ from core temperature?

Answer 4

The are approximately the same.

Question 5

Which temperature measurement is slowest to respond?

Answer 5

Rectal

Question 6

Temperature fluctuates throughout the day. When is it highest? When is it lowest?

Answer 6

Highest: 4pm
Lowest: 4am

Question 7

Name some conditions in which core temperature is elevated

Answer 7

Infection, cancers (eg leukemia, lymphoma), immunological conditions (eg SLE, sarcoid), and hyperthyroidism

Question 8

Name some conditions in which core temperature is depressed

Answer 8

Exposure, hypothyroidism, Addison disease, diabetes mellitus, liver failure, kidney failure

Question 9

Oral temperature measurement: describe the requirements of the patient and the procedure.

Answer 9

Patient should be rested and not have consumed hot or cold beverages for 30 minutes.

Place thermometer under tongue. Patient should breathe through nose and avoid talking.

Question 10

Temporal artery (TA) temperature measurement: describe the technique

Answer 10

Remove the protective cap of the device. Clean contact area with alcohol swab. If needed, clean lens with cotton tip applicator with alcohol and the unit facing down (to avoid EtOH from entering the device).

Push button and slide probe straight across the forehead along the hairline. If perspiration present, also take reading of soft tissue behind the ear. Release button, remove from contact.

Question 11

Normal pulse rate for adult

Answer 11

60-100 bpm

Question 12

T/F: Bradycardia means elevated heart rate

Answer 12

Fale, bradycardia is depressed heart rate. Tachycardia is elevated heart rate

Question 13

What artery is most commonly assessed in taking pulse rate?

Answer 13

Radial (on wrist, on the side of the thumb)

Question 14

How long should you count heart beats for?

Answer 14

30 seconds

Question 15

Name some conditions under which heart rate can be elevated

Answer 15

Infection, anxiety, fever, and heart or respiratory failure

Question 16

T/F: You should measure pulse rate bilaterally on your patient. That is to say you assess both radial arteries

Answer 16

True: you do this to assess symmetry of pulse

Question 17

What does it mean to assess contour of the pulse

Answer 17

Contour is how smooth the increase and decrease in pressure is during a pulse. It should smoothly build from low to high, and back down, as opposed to going from no pressure to high very quickly.

Question 18

Explain the grading system for amplitude of pulse

Answer 18

4+: bounding, as after exercise
3+: increased, as with anxiety
2+: normal, as expected
1+: diminished, barely palpable
0: absent

Question 19

Normal adult respiratory rate

Answer 19

12-18 CPM

Question 20

Normal child respiratory rate

Answer 20

normal up to 20 CPM

Question 21

Normal newborn respiratory rate

Answer 21

normal up to 44 CPM

Question 22

What respiratory rate is considered bradypnea?

Question 23

What respiratory rate is considered tachypnea?

Answer 23

> 20 CPM (for an adult)

Question 24

What is hypercapnea, and what effect does it have on respiratory rate?

Answer 24

CO2 retention, or elevated blood CO2 levels. It results in deep, rapid breathing

Question 25

How is breathing rate assessed

Answer 25

Patient should be unaware that you’re assessing. Perform during the second 30-second block of the 1 minute you’re “assessing pulse”

Question 26

What factors are important when fitting a blood pressure cuff?

Answer 26

1) Cuff must fit properly: too small gives an artificially high reading
2) Artery marker must be placed over the artery
3) Cuff must not be placed over clothing
4) Working stethoscope
5) Quiet room

Question 27

What patient factors are important in taking blood pressure?

Answer 27

1) Rested patient
2) No caffeine intake prior to reading
3) Arm relaxed, supported

Question 28

Describe the blood pressure measurement technique, after set-up

Answer 28

Inflate cuff while palpating radial pulse. Disappearance indicated systolic BP. Inflate cuff another 20-30mmHg. Place stethoscope over brachial artery. Deflate the cuff at a rate of 2-3mmHg/second.

Appearance of first beat is systolic BP. Be sure to confirm that the sound was a heart beat by listening for the second.

Disappearance of beats indicates diastolic BP

If performing multiple readings, wait at least 1 minute

Question 29

What effects of BP does venous congestion have?

Answer 29

Low systolic, high diastolic

Question 30

Is the bell or diaphragm of the stethoscope preferred for BP evaluation?

Answer 30

Bell

Question 31

What should be recorded after blood pressure evaluation?

Answer 31

1) Systolic over Diastolic in mmHg
2) Time of reading
3) Arm used
4) Patient position (sitting, supine)
5) Evaluation using age-appropriate charts