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health assessments and diagnostics > CHAPTER 4 GEN INSPECTION/MEASUREMENT OF VITAL SIGNS > Flashcards

CHAPTER 4 GEN INSPECTION/MEASUREMENT OF VITAL SIGNS Flashcards

1
Q

When does general inspection begin?

A

the moment nurse meets patient

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2
Q

True or false? Assessing presence of pain is considered standard
baseline data collected for all patients and
included with assessment of vital signs.

A

true

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3
Q

body temp is regulated by the ___

A

hypothalamus

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4
Q

how does the body generate heat?

A

heat is gained through the processes of metabolism and exercise

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5
Q

how is heat lost?

A

radiation, convection, evaporation, conduction

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6
Q

What are expected temperature ranges in celsius?

A

35.8-37.3

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7
Q

True or false? 35.8-37.3 C is the body temperature at which cellular metabolism is most efficient

A

true

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8
Q

True or false? emperature during menstrual cycle increases
from 0.5° F to 1.0° F (0.3° C to 0.6° C) at
ovulation and remains elevated until menses
cease because of progesterone secretion

A

true

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9
Q

Diurnal variations of _ F to _ F occur, with the
lowest temperature in the _____ and highest in the
late _____.

A

1, 1.5, morning, afternoon

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10
Q

a patient has just ingested hot or cold liquids or was smoking. how long should we wait to take their temperature orally?

A

10 minutes

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11
Q

how is oral temperature taken?

A

Electronic thermometer (sheathed): under
tongue in sublingual pocket for 15 to 30
seconds

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12
Q

true or false? the sublingual pocket receives blood supply from carotid artery, indirectly reflecting core temperature.

A

true.

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13
Q

in which populations are oral temps most often taken?

A

school-aged children, confused adults

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14
Q

how are tympanic temperatures taken?

A

Probe covered with protective sheath, placed in
external ear canal in contact with all sides of canal
for 2 to 3 seconds

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15
Q

true or false? axillary temperature measurement is very accurate.

A

false. axiallary temperatures have questionable accuracy.

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16
Q

heart rate vs rhythm

A

heart rate = number of times per minute a pulsation is felt
rhythm = regularity of pulsations

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17
Q

If pulse rhythm is irregular, note any odd rhythm, and
count pulsations for how long?

A

a full minute. basically do it again

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18
Q

Radial artery is most frequently used to measure
heart rate because

A

accessible and easily
palpated

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19
Q

where is the radial pulse found?

A

radial side of forearm at wrist

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20
Q

where is the brachial pulse found?

A

groove between biceps and triceps, in bend of elbow

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21
Q

where is the carotid pulse found?

A

the medial edge of sternocleidomastoid muscle in lower third of neck

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22
Q

heart rate is sometimes assessed by auscultating heart, which is known as ___

A

apical pulse

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23
Q

where is the apical pulse found

A

located over the 5th intercostal space at the midclavicular line

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24
Q

true or false? men usually breathe diaphragmatically, whereas women are usually thoracic breathers

A

true.

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25
Q

why should we count respirations when patients are unaware?

A

to prevent them from getting nervous and changing their breathing patterns

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26
Q

factors that increase respiratory rate

A

fever, anxiety, exercise, high altitude

27
Q

should breathing be loud and labored at rest?

A

no.

28
Q

small volume of air movement in and out of lungs

A

shallow breathing

29
Q

force of blood agaisnt arterial walls

A

blood pressure

30
Q

reflects relationship between cardiac output and peripheral resisistance

A

blood pressure

31
Q

____ is the force that opposes flow of blood through vessels

A

peripheral resistance

32
Q

When arteries are narrow = peripheral resistance to blood flow
is high =

A

elevated blood pressure

33
Q

blood pressure is dependent on ___ of blood, ___ blood ____, and ____ of vessel walls

A

velocity, intravascular, volume, elasticity

34
Q

how is blood pressure measured?

A

mm Hg millimeters of mercury

35
Q

maximum pressure exerted on arteries when ventricles eject blood from heart

A

systolic blood pressure

36
Q

represents minimum amount of pressure exerted on vessels when ventricles of heart relax

A

diastolic blood pressure

37
Q

blood pressure top and bottom numbers

A

top=systolic
bottom=diastolic

38
Q

pulse pressure

A

difference between systolic and diastolic pressures. normally ranges from 30 mm Hg to 40 mm Hg

39
Q

orthostatic blood pressure

A

series obtained when the patient is lying, sitting, and then standing

40
Q

direct (invasive) blood pressure method

A

insertion of a small catheter into an artery that provides continuous blood pressure measurements and arterial waveforms

41
Q

when is direct blood pressure used?

A

critical care settings where continuous monitoring is required

42
Q

indirect measurement of blood pressure

A

most commonly used/ auscultation with sphygomomanometer and stethoscope or w/ noninvasive blood pressure monitoring

43
Q

when auscultating blood pressure, listen for

A

korotkoff sounds

44
Q

mechanism of blood pressure measurement

A

blood flows freely through artery until inflated cuff interrupts the flow. as it slowly deflates, nurse listens for sounds of blood pulsating through artery again.

45
Q

initial sound and point at which systolic pressure is detected

A

first korotkoff sound.

46
Q

swishing sound heard as cuff continues to deflate

A

second korotkoff sound

47
Q

korotkoff sound w/ softer thump than the first

A

3rd

48
Q

muffled, low pitched sound as cuff is further deflated

A

4th korotkoff sound

49
Q

sound which determines diastolic pressure

A

5th korokoff sound. last beat

50
Q

electronic device attached to a cuff

A

NIBP

51
Q

incidence of hypertension is twice as high in black americans than whites. true or false?

A

true

52
Q

men have higher blood pressures than women until when?

A

menopause, when women’s may become higher

53
Q

blood pressure diurnal variations

A

pressure lower in early morning, peaks in late afternoon or early evening

54
Q

device that estimates oxygen saturation of
hemoglobin in blood

A

pulse oximeter

55
Q

where can pulse oximeters be placed?

A

finger, toe, earlobe, nose

56
Q

by what age is adult height attained?

A

18-20 years old

57
Q

True or false? using too small of a blood pressure cuff can cause a patient’s systolic blood pressure to increase 10 to 40 mmHg

A

true

58
Q

How far should a rectal thermometer go?

A

1.25 to 2.5 centimeters

59
Q

pulse strengths

A

0= absent +1 diminished +2 normal +3 full volume +4 full volume and bounding

60
Q

why should we check carotid pulses at the base of the neck?

A

taking them too high up can result in pushing on the sinuses and causing patients to faint

61
Q

how long should we count apical pulses?

A

always the full minute

62
Q

how are intercostal spaces named?

A

for the rib directly above it

63
Q
A

health assessments and diagnostics (12 decks)

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