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NUR155 Theory > Vital Signs Chapter 19 > Flashcards

Vital Signs Chapter 19 Flashcards

1
Q

These allow the nurse to detect changes in the health status of the patient, identify early warning signs of life-threatening health conditions, and evaluate effectiveness of interventions.

A

Vital signs

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2
Q

Vital signs consist of what 5 things?

A

Temperature, pulse, respirations, blood pressure, and pulse oximetry

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3
Q

Vital sign: measurable heat of the human body. What is the normal range?

A

Temperature; 97.6-99.6

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4
Q

Vital sign: detectable rhythmic expansion of an artery that occurs with the pumping action. What is the normal range?

A

Pulse; 60-100 BPM

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5
Q

Vital sign: act of breathing measured in beats per minute. What is the normal range?

A

Respiration; 12-20 BPM

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6
Q

Vital sign; the measurable pressure of blood within the systemic arteries. What is the normal range?

A

Blood pressure; systolic 90-120, diastolic 60-80.

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7
Q

Vital sign; measures the amount of oxygen available to tissues. What is the normal range?

A

Pulse oximetry; 95%-100%

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8
Q

Infection, physical environment, emotional state of patient, medications, fluid and food intake, activity level and tolerance are all factors that influence what?

A

Factors that influence vital signs.

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9
Q

Age, exercise, hormone fluctuations, circadian rhythms, stress, environment, and smoking are all factors that influence what?

A

Factors that influence temperature.

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10
Q

Condition of low body temperature. signs and symptoms include respirations, pale, cool skin, and decreased blood pressure.

A

Hypothermia

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11
Q

Condition of high body temperature.

A

Hyperthermia

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12
Q

This condition occurs when prolonged exposure to the sun or high environmental temperatures overwhelms the body’s heat loss mechanisms.

A

Heat stroke

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13
Q

This condition occurs when extreme or prolonged environmental heat exposure leads to profuse sweating with consequent excessive water and electrolyte loss.

A

Heat exhaustion.

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14
Q

What are the 5 common sites used to measure temperature?

A

Mouth, ear, rectum, forehead, axilla

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15
Q

This selection is affected by patient’s age, state of consciousness, amount of pain the patient is suffering, and treatment the patient is undergoing.

A

Site selection of temperature

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16
Q

Pulse is measured through which 9 areas? TCABRFPPtD

A

Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior tibial, Dorsalis pedis

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17
Q

This pulse site is located at neck area and both should not be palpated at the same time because it could limit blood flow to the brain.

A

Carotid site

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18
Q

This pulse site is located at the apex of the heart, at the fifth intercostal space midclavicular line. AKA Point of maximal impulse.

A

Apical pulse

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19
Q

This pulse site is located at the inner aspect of the arm and used to assess pulse in pediatric emergencies

A

Brachial pulse

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20
Q

This pulse site is located at femoral artery and used in cases of cardiac arrest and for assessing circulation to the leg.

A

Femoral pulse

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21
Q

This pulse site is at medial surface of the ankle and used to determine circulation of the foot.

A

Posterior tibial pulse.

22
Q

This pulse site is used to determine circulation of the foot.

A

Dorsalis pedis pulse

23
Q

Listening with a stethoscope is considered what?

A

Auscultation

24
Q

An excessively fast heart rate of greater than 100 bpm

A

Tachycardia

25
Q

A slow heart rate of less than 60 bpm is called what?

A

Bradycardia

26
Q

Present when the patient’s radial pulse rate is slower than the apical pulse because of cardiac contractions that are ineffective at pumping blood to the peripheral extremities.

A

Pulse deficit

27
Q

An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat.

A

Dysrhythmia or arrhythmia

28
Q

Normal respiration with a normal rate and depth for the patient’s age

A

Eupnea

29
Q

An increase in respiratory rate of more than 24 BPM in the adult.

A

Tachypnea

30
Q

A decrease in respiratory rate to less than 10 BPM. Can be caused by medications, opioids, metabolic disorders, or brain injury.

A

Bradypnea

31
Q

Characterized by shallow respirations; associated with drug overdose and obesity, cervical spine injury, and COPD (chronic obstructive pulmonary disease).

A

Hypoventilation

32
Q

Characterized by deep, rapid respirations. Often caused by stress and anxiety.

A

Hyperventilation

33
Q

The absence of breathing; brain damage can occur after 4-6 minutes of this.

A

Apnea

34
Q

Shortness of breath or difficult, labored breathing with rapid shallow pattern.

A

Dyspnea

35
Q

Difficulty breathing when lying flat that is relieved by sitting or standing

A

Orthopnea

36
Q

The peak of blood pressure wave is called what? Where the heart contracts.

A

Systolic pressure

37
Q

The lowest pressure on arterial walls, which occurs when the heart rests is called what? Where the heart dilates.

A

Diastolic pressure

38
Q

Blood pressure is measured in what?

A

Millimeters of mercury (mm Hg)

39
Q

This condition is when systolic blood pressure is less than 90 mm Hg. Or 20-30 mm Hg below the patient’s normal blood pressure.

A

Hypotension

40
Q

A sudden drop of 20 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the patient moves from lying to sitting to standing.

A

Orthostatic hypotension

41
Q

Elevated blood pressure that can lead to myocardial infarction, stroke, renal failure, and death.

A

Hypertension.

42
Q

The sounds in which the nurse listens to when assessing blood pressure.

A

Korotkoff sounds

43
Q

The absence of Korotkoff sounds noted in some patients after the initial systolic pressure. Failure to recognize this can cause major errors in measuring blood pressure.

A

Auscultatory gap

44
Q

Landmark for heart auscultation: located in 2nd intercostal space right of the sternal border.

A

Aortic valve

45
Q

Landmark for heart auscultation: located in 2nd intercostal space left of the sternal border.

A

Pulmonic valve

46
Q

Landmark for heart auscultation: located at 5th intercostal space left of the sternal border.

A

Tricuspid valve

47
Q

Landmark for heart auscultation: located at 3rd intercostal space, left of the sternal border.

A

Erb’s point

48
Q

Landmark for heart auscultation: located at 5th intercostal space, mid clavicular line (apical pulse)

A

Mitral valve

49
Q

A condition that causes an increased lumbar curvature just above the buttocks area.

A

Lordosis

50
Q

An outward curvature of the thoracic spine.

A

Kyphosis

51
Q

A sideways or s-shaped curvature of the spine and is always abnormal.

A

Scoliosis

NUR155 Theory (20 decks)

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