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level: Level 1

Questions and Answers List

level questions: Level 1

QuestionAnswer
When measuring vital signs what can happen?a change in one has the potential to alter the others
When measuring vital signs what can happen?a change in one has the potential to alter the others
When measuring vital signs what can happen?a change in one has the potential to alter the others
indication of basic body functioning, it is appropriate to begin the physical assessment by obtaining these datavital signs
ausculatelisten for sounds within the body to evaluate the condidion
What should be included in an overall assessment for all patients?cultural assessment
What are the guidelines for obtaining vital signs?measuring them correctly, understanding & interpreting the values, communicating findings appropriately, beginning interventions as needed
High temperatureBody can be fighting off infection
High B/PPatient can be prone to having a stroke
What is the 5th vital sign?Pain or comfort level
What do you need to be aware of for patients' vital signs?The normal range
What helps maintain a balance between heat lost & heat produced by the body?Hypothalamus
2 types of body temperaturecore temp & surface temp
core tempdeep tissue of the body; remains relatively constant
surface temptemperature of the skin
When taking a patient's temp what do you need to remember to always do?Always note where you took it
HypertensionHigh blood pressure
Fevera body defense mechanism
What happens when the body temp is elevated?helps destroy invading bacteria
Radial Pulse Rateis obtained at the radial artery thumb
What pulse rate will you check the LOC?Thumb (Radial Pulse)
Where will you find a quick pulse?Carotid
Remittentfluctuates, does not return to normal until feeling better
intermittentrise/falls to normal everyday ex: normal in the morning & spikes in the after noon
apical pulseactual beating of heart
Lub-Dubone cardiac cycle
If pulse differs by more than 2 then what exist?pulse deficit exists
internal resperationgas exchange on tissue level
paracentesisfluid out of the lungs
What is considered as a silent killer?Hypertension
Apneastopped breathing
When taking a patient's vital signs what do you need to be aware of?The normal Range
What do you need to report while doing vital signs?Abnormalities
How frequently are vital signs measured?Depend on the nurse's judgment of the need
Neonate Heart Rate120-160 per minute
Neonate Resp. Rate36-60 per minute
Neonate B/PSystolic 20-60
Infant Heart Rate125-135
Infant Resp. Rate40-46
Infant B/PSystolic 70-80
Toddler Heart Rate90-120
Toddler Resp. Rate20-30
Toddler B/PSystolic 80-100
School Age Heart Rate65-105
School Age Resp. Rate22-24
School Age B/PSystolic 90-100 Diastolic 60-64
Adolescent Heart Rate65-100
Adolescent Resp Rate16-22
Adolescent B/PSystolic 100-120 Diastolic 70-80
Adult Heart Rate60-100
Adult Resp. Rate12-20
Adult B/PSystolic 100-120 Diastolic 70-80
Older Adult Heart Rate60-100
Older Adult Resp. Rate12-18
Older Adult B/PSystolic 130-140 Diastolic 90-95
temperaturea relative measure of sensible heat or cold of 98.6 which is considered normal
When the patient reports nonspecific symptoms of physical distress (feeling funny or different)Take vital signs
Before and after administering meds specially those that affect cardiovascular, respiratory, & temperature control function what should you make sure to do?Take vital signs
Normal body temperature for oral98.6,37.0
Normal body temperature for rectal99.6,37.5
Normal body temperature for axillary97.6,36.4
Normal body temperature for tympanic/temporal98.6,37.0
Where is the hypothalamus located?In the brain and forms the floor & part of the lateral wall of the third ventricle
Often varies a great deal in response to the environmentsurface temperature
pyrexia, febrile & hyperthermiaused to describe the condition of having above-normal body temperature
Temperatures exceeding 105have the potential to damage normal body cells
What are fever classified as?constant, intermittent, & remittent
constant feverremains elevated consistently and fluctuates very little
Hypothermiabody temperature is abnormally low
when the body temp falls below 93.2death is a risk
hypothyroidismproduce a subnormal temperature
Factors that affect body temperatureAge, exercise, hormonal influences, diurnal (daily) variations, stress, environment, ingestion of food & hot & cold liquids, & smoking
What are some signs & symptoms of elevated body temp?anorexia, disorientation, elevated pulse/respirations, warm skin, headache, irritability,thirst
Tympanictemperature by scanning the tympanic (eardrum) membrane
What are the instructions for tympanic probe positioning?Gently tug ear pinna upward and back for an adult, down and back for a child
stethoscopean instrument that is placed against the patient's chest or back to hear heart & lung sounds
cultatelisten for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones
Oral tempmost accessible site; comfortable for patient; necessitates no position change
Rectal tempargued to be more reliable when oral temperature cannot be obtained
Axilla tempsafe method because noninvasive
Tympanic Temperaturenoninvasive, accurate, safe; provides core reading
Temporal artery tempprovides core temperature; rapid, noninvasive method; tolerated well by children; lessens need to handle newborns, which aids in preventing heat loss
What is the least accurate method to take a temp?Axilla
pulsea rhythmic beating or vibrating movement
what does pulse signify?the regular recurrent expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts
tachycardiapulse is faster than 100 beats per minute
bradycardiapulse slower than 60 beats per minute
hypovolemiaan abnormally low circulating blood volume
What may cause tachycardia?shock, hemorrhaging, exercise, fever, medication, or substance abuse, and acute pain
What may cause bradycardia?unrelieved severe pain; stimulates the parasympathetic nervous system, which slows the heart rate
dysrhythmiaany disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart
imperceptiblea pulse you are unable to feel at all
What do you do when taking the pulse?Note the rate, the rhythm, and the volume or strength of the pulse
Factors that influence pulse ratesacute pain/anxiety, age, exercise, fever/heat, hemorrhage, medications, metabolism, postural changes, pulmonary conditions, unrelieved severe pain/chronic pain
absent pulse (0)none felt
Thready pulse (1+)Difficult to feel; not palpable when only slight pressure applied
weak pulse (2+)somewhat stronger than a thready pulse but not palpable when light pressure applied
normal pulse (3+)easily felt but not palpable when moderate pressure applied
bounding pulse (4+)feels full & springlike even under moderate pressure
What does a pulse deficit signifies?the pumping action of the heart is faulty or there is a peripheral vascular issue
What are all the pulse sites?temporal, carotid, apical, brachial, radial, femoral, popliteal, dorsalis pedis
pulse deficita difference between the radial and the apical rates
respirationthe taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; act of breathing is internal & external
internal respirationrefers to the exchange of gas at the tissue level caused by the process of cellular oxidation
external respirationbreathing movements of the patient that are observed
what is the rate of respiration controlled by?medulla oblongata
Two parts of external respirationinspiration & expiration
inspirationinhaling air with oxygen into the lungs
expirationexhaling air with carbon dioxide out of the lungs
tachypneaa rapid respiratory rate
bradypneaslow respiratory rate, below 10 per minute
when assessing respirations what do you note?the rate, depth, the quality, & the rhythm
dyspneabreathing with difficulty
Cheyne-Stokes respirationsan abnormal pattern of respiration characterized by alternating period of apnea and deep rapid breathing
point of maximal impulseis at 5th intercostal space. MCL, midclavicular line; PMI, point of maximal impulse
Hypoventilationoccurs when the rate of ventilation entering the lungs is insufficient for metabolic needs
Factors that influence respirationacute pain, age, body position, brainstem injury, disease or illness, exercise, fever, gender, hemoglobin function, medications, smoking, stress
blood pressurethe pressure exerted by the circulation volume of blood on the arterial walls, the veins, and the chambers of the heart
systolic pressurethe higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries
diastolic pressurelower number represents the pressure within the artery between beats, that is, between contractions of the atria or the ventricles, when blood enters the relaxed chambers from the systemic circulation and the lungs
pulse pressuredifference between the two readings systolic/diastolic
cardiac outputthe amount of blood discharged from the heart per minute
prehypertensionvalues of 120-139/80-89 mm Hg
hypertensionoccurs when the elevated pressure is sustained above 140/90 mm Hg
kussmaulrapid, deep labored respirations
what are the patterns of respiration?normal, hyperventilation, bradypnea, sighing, tachypnea, Cheyenne-Stokes, Kussmaul
Hypertension ismost common form
Risk factors for hypertensionhistory of hypertension, obesity, smoking, heavy alcohol consumption, elevated blood cholesterol level & stress
hypotensionblood pressure below normal
orthostatic hypotensiona drop of 25mm Hg in systolic pressure and a drop of 10mm Hg in diastolic pressure when a person moves from a lying to a sitting or from a sitting to a standing position
factors that influence blood pressureage, alcohol & tobacco use, anxiety, diet, diurnal (happening daily), gender, hormones, medications, obesity, race
sphygmomanometerdevice for measuring the arterial blood pressure
Korotkoff soundspulsating sounds from brachial artery
Stage 2 hypertension160 or higher -100 or higher
hypertensive crisishigher than 180-higher than 110
Lowers pressurehemorrhage, general anesthesia, & postural change
Raises pressureincreased intracranial pressure, acute pain, end-stage renal disease, primary essential hypertension, exercise, & smoking
why is height and weight determination important?it helps assess normal growth and development, aids in proper drug dosage calculation, and often is used to assess the effectiveness of drug therapy such as diuretics
When weighing a patient what should you do?weigh them at the same time of day, same scale, & the same type of clothing
how should you approach patient while setting up for vital signs?calm and caring manner
when are vital signs best measured?inactive (at rest) and the environment is controlled for comfort
What is no longer in use because of the danger of mercury toxicity?use of in-glassmercury thermometers
who should you not perform rectal temp measurements on?newborns, infants, or adults with rectal alterations
tympanic routemost accessible and acceptable site for measuring core body temperature
why would you assess presence & character of peripheral pulsesto determine the adequacy of peripheral blood flow
When is the automatic blood pressure cuff useful?for home use if the patient or caregiver has hearing difficulties
When measuring vital signs what can happen?a change in one has the potential to alter the others