NURSING II: FON - Ch 29 Vital Signs

Question 0

Vital Signs are used to (3):

Answer 0

1. MONITOR patient condition
2. IDENTIFY problems
3. EVALUATE response to interventions

Question 1

Vital Signs: Assessments (6)

Answer 1

1. Temperature
2. Pulse (P), including (Apical)
3. Blood Pressure (BP)
4. Respiratory Rate (RR)
5. Oxygen Saturation (SaO2)
6. Pain (1-10)

Question 2

Acceptable TEMPERATURE range for adults:

Answer 2

96.8F - 100.4F

36C - 38C

Question 3

Average ORAL/TYMPANIC TEMPERATURE for adults:

Answer 3

98.6F

37C

Question 4

Average RECTAL TEMPERATURE for adults:

Answer 4

99. 5F

37. 5C

Question 5

Average AXILLARY TEMPERATURE for adults:

Answer 5

97. 7F

36. 5C

Question 6

Acceptable PULSE range for adults:

Answer 6

60 - 100 bpm

Question 7

Acceptable BLOOD PRESSURE (BP) range for adults:

Answer 7

<120 / <80 mmHg

Question 8

Acceptable PULSE PRESSURE (PP) range for adults:

Answer 8

30 - 50 mmHg

Question 9

Acceptable RESPIRATORY RATE (RR) range for adults:

Answer 9

12 - 20 bpm

Question 10

Non-invasive Sites of TEMPERATURE measurement (5):

Answer 10

1. Oral
2. Rectal
3. Axillary
4. Tympanic Membrane
5. Temporal Artery

Question 11

Invasive Sites of TEMPERATURE measurement (3):

Answer 11

1. Esophageal
2. Pulmonary Artery
3. Urinary Bladder

Question 12

Factors that affect Body Temperature (6):

Answer 12

1. Age
2. Exercise
3. Hormone Level
4. Circadian Rhythm
5. Stress
6. Environment

Question 13

4 Stages of a Fever:

Answer 13

1. Sustained
2. Intermittent
3. Remittent
4. Relapse

Question 14

SUSTAINED stage of a fever:

Answer 14

Constant temperature (little fluctuation) above 100.4F
(Keep patient cool)

Question 15

INTERMITTENT stage of a fever:

Answer 15

Fever will spike, then returns to acceptable level at least once within 24 hours

Question 16

REMITTENT stage of fever:

Answer 16

Fever spikes, then falls without return to normal temperature levels

Question 17

RELAPSE stage of a fever:

Answer 17

Periods of Febrile Episodes, and periods of with acceptable temp. values

Question 18

Pyrexia: Important defense mechanism. Also called, ___.

Answer 18

Fever

Question 19

Bacteria or viruses are also called, ___.

Answer 19

Pyrogens

Question 20

True/False: Pyrogens trigger the immune response.

Answer 20

True

Question 21

The phase when pyrogens are removed and heat loss responses occur (chills)

Answer 21

Febrile Episode

Question 22

When the fever breaks, it is called ___.

Answer 22

afibrile

Question 23

FUO

Answer 23

Fever of Undetermined Origin

Question 24

Condition when body temperature reaches 104F or more

Answer 24

Heat Stroke

Question 25

Inability of body to promote heat loss or reduce heat production

Answer 25

HYPERthermia

Question 26

Heat loss during a prolonged exposure to cold; overwhelms body ability to produce heat.

Answer 26

HYPOthermia

Question 27

GOAL & OUTCOME when patient has elevated temperature and diaphoresis

Answer 27

The GOAL is attaining fluid and electrolyte balance

The desired OUTCOME: Patient I&O will be equal for next 24 hrs

Question 28

Nursing INTERVENTIONS for fever

Answer 28

1. Blood cultures (before antibiotics)
2. Minimize heat production
3. Maximize heat loss
4. Req. for increased metabolic rate
5. Promote patient comfort
6. Control environmental temp

Question 29

5 major parts of a Stethoscope:

Answer 29

1. Earpieces
2. Binaurals
3. Tubing
4. Bell Chest Piece
5. Diaphragm Chest Piece

Question 30

Difference between Apical Pulse Rate and Radial Pulse Rate

Answer 30

Pulse Deficit

Question 31

Pulse Deficits are often associated with ___ ___.

Answer 31

abnormal rhythms.