Chapter 7 *

Question 1

what are the pulse location on the body cephalocaudal order

Answer 1

temporal artery, common carotid artery, apical, brachial artery, radial artery, femoral artery, popliteal artery, posterior tibial artery, dorsalis pedis

Question 2

What is tachycardia

Answer 2

heart rate of 100 or more.

Question 3

Is tachycardia an indicator for respirations?

Answer 3

No, it is an indicator for pulse

Question 4

What is bradycardia

Answer 4

heart rate below 60

Question 5

Is bradycardia an indicator for pulse or heart function

Answer 5

Yes, pulse is a indicator of heart function.

Question 6

Dyspnea

Answer 6

difficulty breathing

Question 7

Tachypnea

Answer 7

rapid rate of respirations more than 20 breaths per minute

Question 8

bradypnea

Answer 8

less than 12 breathes per minute

Question 9

Hypoventilation

Answer 9

shallow, slow breathing, which can be related to sedation

Question 10

Hyperventilation

Answer 10

deep, rapid breathing usually from hypoxia, anxiety, or exercise

Question 11

Orthopnea:

Answer 11

difficulty breathing unless sitting or standing

Question 12

Cheyne-stokes:

Answer 12

rhythmic waxing and waning of respirations

Question 13

Apnea:

Answer 13

cessation of breathing

Question 14

Biot’s respirations:

Answer 14

shallow breathing with periods of apnea

Question 15

Kussmaul’s breathing:

Answer 15

deep and rapid breaths

Question 16

normal range for pulse ox is

Answer 16

95-100%

Question 17

anemia is (in regarding pulse ox) ?

Answer 17

A lack of oxygen circulating in the blood with a pulse ox reading of 90% or below

Question 18

Oral tempature

Answer 18

The oral temperature is the most accessible, convenient, and accurate method. Oral temperatures are obtained by using an electronic or digital probe device in a hospital setting. Glass mercury thermometers are no longer used in the clinical setting.

Question 19

Rectal tempature

Answer 19

A rectal temperature is obtained if the client is comatose, confused, having seizures, or is unable to close his or her mouth.

Question 20

Axillary tempature

Answer 20

This is the safest method as it is less invasive compared to the oral or rectal route. This route is also considered the least accurate due to the variety of possible probe positions.

Question 21

Tympanic tempature

Answer 21

The tympanic temperature is taken with an electronic thermometer using an infrared probe. Placing the probe in the client’s ear gives a core temperature quickly and accurately.

Question 22

Temporal Artery tempature

Answer 22

The temporal thermometer is noninvasive and scans over the forehead across the temporal artery. This convenient method displays the temperature within seconds.

Question 23

Hypothermia

Answer 23

most common body response to prolonged exposure to cold.

Question 24

Blood pressure sounds (also called Korotkoff sounds) change over the duration of the blood pressure monitoring procedure. The five phases are described as follows

Answer 24

1. Initial sounds are faint with a clear tapping quality.
2. Distinctive swishing sounds are heard.
3. Similar tapping sounds as Phase 1 yet with greater intensity.
4. Muffled sounds ensue.
5. The sounds disappear.

Question 25

hyperthermia

Answer 25

Fever corresponding to viral or bacterial infection. usually from tissue breakdown following myocardial infarction, malignancy, surgery or trauma.

Question 26

what are the factors that influence body temperature?

Answer 26

age, diurnal variations, exercise, hormones, stress, illness.

Question 27

vital signs

Answer 27

temperature, pulse, respiratory rate, blood pressure, and pain.

Question 28

how is oxygen saturation measured?

Answer 28

pulse oximeter

Question 29

what are the 4 factors that considered when assessing the pulse?

Answer 29

rate, rhythm, force, elasticity.

Question 30

what are the circulatory factors that influence Blood Pressure?

Answer 30

Cardiac output-amount of blood ejected by the heart

Blood Volume-total amount of blood circulating within the entire vascular system

Peripheral vascular resistance- resistance the blood encounters as it flows within the vessels.

Blood viscosity-the ratio between the blood cells and the blood plasma

Vessel Compliance-the elasticity of the smooth muscle in the arterial walls.

Question 31

O
L
D
C
A
R
T
&
I
C
E

Answer 31

O- Onset
L-Location 
D-Duration 
C-Characteristics 
A-Aggravating factors 
R-Relieving Factors 
T-Treatment 
&
I-Impact on ADL's
C-Coping strategies 
E-Emotional Response

Question 32

Functional Assessment

Answer 32

is an observation to gather data while the client is performing common or routine activities.

Question 33

what are the four major categories observed during General survey?

Answer 33

physical appearance-provides immediate cues to the level of individual wellness. (undernourished, skin color, gestures)

mental status- orientated to time place and person.

mobility- range of motion posture and gait.

behavior- dress and grooming, body odors, facial expression, mood and ability to make eye contact as well as level of anxiety.

Question 34

Systolic pressure

Answer 34

the pressure of blood at the height of the wave when the left ventricle contracts. (first number in blood pressure)

Question 35

Diastolic pressure

Answer 35

the pressure between the ventricular contractions when the heart is at rest. (second number in blood pressure)

Question 36

what behaviors indicate a client is in pain?

Answer 36

facial grimacing, moaning, crying or screaming, guarding, or immobilization of body part, tossing or turning and rhythmic movements.

Question 37

pain’s physiologic response

Answer 37

Sympathetic response is demonstrated in elevation of blood pressure, pulse and respiratory rates, pallor, and diaphoresis.

Parasympathetic stimulation often accompanies visceral pain. resulting in lowered blood pressure and pulse rate and warm dry skin.

Question 38

Regulates temperature in the body

Answer 38

Hypothalamus

Question 39

Stroke volume

Answer 39

the amount of blood pumped from the heart with each heartbeat

Question 40

Compliance

Answer 40

the ability of the arteries to contract and expand

Question 41

How does position changes affect the pulse rate?

Answer 41

when sitting or standing for long periods, blood may pool in the veins, resulting in a temporary decrease in venous blood return to the heart and consequently, reduce blood pressure and lowered pulse rate.

Question 42

how would a fever affect pulse rate?

Answer 42

pulse rate increases. ( the peripheral vasodilation that accompanies an elevated body temperature lowers systemic blood pressure)

Question 43

Age related considerations while assessing height and weight

Answer 43

infants- should be placed on an examining table on a supine position. with a ruler, headboard and adjustable footboard. infants are weighed on a modified platform scale with curved sides to prevent injury.

children 2 or 3- may be weighed on the upright scale or seated on the infant scale. to assess height the nurse uses the platform scales or a measuring stick attached to the wall.

Adult- weight platform scale. height measuring stick.

older adults-height declines with age, because the thinning or compression of the intervertebral disks and a general flexion of the hips and knees. weight may decrease because of muscle shrinkage.