quiz 1

Question 1

The hypothalamus impact on vital signs

Answer 1

the hypothalamus controls body temp, senses minor changes in the body temperature. The anterior hypothalamus controls heat loss and the posterior hypothalamus controls heat production.

Question 2

Newborn and infant temperature regulation

Answer 2

temperature control mechanisms are immature - responds drastically to changes in the environment.
they can lose up to 30% of their body eat through their head, therefore need to wear a cap to prevent heat loss.
when protected from environmental extremes, the newborns body temp is within 35.5 -37.5 degrees Celsius

Question 3

Critical thinking related to vital signs

Answer 3

• it is the nurses responsibility to review vital sign data, interpret their significance, and critically think through decisions about interventions.
  -use VS measurements to determine indication for medication administration.
• Analyze the results of vital sign measurements on the basis of the pt’s condition and past health history.
  -Verify and communicate significant changes in vital signs

Question 4

Purpose of stethoscope

Answer 4

Amplifies internal body sounds from the heart, lungs, and bowels. Each sound has a “normal” frequency range that doctors listen for

Question 5

purpose of thermometer

Answer 5

measure body temperature. 96.8-100.4 F (36-38 degrees Celsius)

Question 6

Sphygmomanometer

Answer 6

Measures blood pressure.
Systolic < 120 mmHg
Diastolic <80 mmHg

Question 7

Routes to assess temperature and range

Answer 7

Average temperature range: 36° to 38°C (96.8° to 100.4°F)

Average oral/tympanic: 37°C (98.6°F)
Average rectal: 37.5°C (99.5°F)
Axillary: 36.5°C (97.7°F)
Temporal 37C (98.6F)

Question 8

Technique for checking radial pulse

Answer 8

radial or thumb side of the forearm at the wrist. Common site used to assess character of pulse peripherally and status of circulation to hand.

Question 9

checking carotid pulse

Answer 9

Along medial edge of sternocleidomastoid muscle in neck. Easily accessible site used during physiological shock or cardiac arrest when other sites are not palpable

Question 10

technique for checking pedal pulse

Answer 10

posterior tibial- (inner side of the ankle, below medial malleolus). Dorsalis Pedis (top side of the foot, medially)

Question 11

Strategy to obtain respirations

Answer 11

range is 12-20 breaths per min.
Do not let a patient know that you are assessing respirations. Quietly observe the patient’s breathing and when appropriate begin to count the rate. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient’s wrist as it rests over the chest or abdomen. In children, measure respirations first, before other vital signs.

Question 12

Impact of alcohol, smoking, and caffeine on VS

Answer 12

Alcohol: Increase heart rate, Increase BP, weaken heart muscles, and irregular heartbeat.

Smoking: Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15 minutes after stopping smoking.

Caffeine: Can elevate Heart rate and blood pressure.

Question 13

Proper action and documentation when medication administration parameters are not met

Answer 13

Document name of medication, dose, route, and time administered on MAR. Document patient’s response in nurses’ notes of MAR in the electronic health record (EHR) or chart.

Question 14

apical pulse site

Answer 14

@ 5th intercostal space, down from left clavicle (heart side)

Question 15

popliteal pulse site

Answer 15

behind knee