Chapter 10 and 11: Vitals and Pain

Question 1

Vital signs to be assessed include:

Answer 1

Temperature
Pulse or heart rate
Respirations
Blood pressure
Pulse oximetry

Question 2

Body temperature is regulated by

Answer 2

the hypothalamus

Question 3

the hypothalamus

Answer 3

a small endocrine gland in the center of the brain

Question 4

normal body temperature

Answer 4

97.2° to 100° Fahrenheit or 36.2° to 37.7° Celsius

Question 5

Which method is best for measuring the temperature of a critically ill patient who is catheterized?

Answer 5

Thermistor port temperature

Question 6

What are the specific body locations where the artery is superficial enough for the nurse to effectively palpate the pulse?

Answer 6

Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Apex of the heart
Apical pulse

Question 7

Normal Pulse range

Answer 7

60 to 100 beats per minute

Question 8

The amplitude of the pulse indicates

Answer 8

the strength of the ventricular contractions, amount of circulating blood volume, and blood vessel tone.

Question 9

What are the different pulse descriptions?

Answer 9

weak, strong, or bounding

Question 10

When palpating the arterial pulse, expected findings include:

Answer 10

Pulse rate between 60 and 100 beats per minute
Regular rhythm
Strong amplitude
Contour with smooth upstroke and downstroke

Question 11

Pulse rates below 60 are common for elite athletes and people taking

Answer 11

beta blocker medications

Question 12

Pain is what

Answer 12

It is whatever the pt says it is. It is subjective

Question 13

What types of self-reporting pain scales are available to the nurse to help patients relate their pain?

Answer 13

Descriptive

Visual

Numeric

Question 14

How can the nurse achieve the most consistent interpretation of patient pain ratings?

Answer 14

Use the same set of pain scales other nurses use

Question 15

What vital signs may be expected to change in the patient with acute pain?

Answer 15

BP
Respiratory
Pulse

Question 16

A patient in acute pain may vocalize his or her pain in which ways?

Answer 16

Grunting
Crying
Groaning

Question 17

The nurse is assessing a nonverbal adult. What nonverbal vocal complaints would indicate pain?

Answer 17

(grunting, moaning, gasping), facial grimaces and winces, bracing, restlessness, and rubbing

Question 18

Conditions that stimulate the sympathetic nervous system are

Answer 18

exercise, stress, fear, caffeine intake, some medications—may increase the pulse rate and amplitude

Question 19

An adult patient is bradycardic if the pulse is less than __ beats per minute.

Answer 19

60

Question 20

Respiration

Answer 20

the measure of inspiration and expiration

Question 21

What happens during inspiration?

Answer 21

the diaphragm moves downward, allowing air to fill the lungs. This is followed by expiration, when the air is forced out of the lungs.

Question 22

How to accurately assess respirations?

Answer 22

assess respirations, the nurse should note how many breaths the patient takes in 1 minute. To do this, the nurse should count for 30 seconds and multiply by 2

Question 23

Expected findings when assessing respirations include:

Answer 23

No dyspnea, or difficulty breathing
Regular rhythm, or pattern of breathing
Rate between 12 and 20 breaths per minute
Pronounced thoracic movement when sitting up; pronounced abdominal movement when lying supine

Question 24

The nurse should measure respiratory rate immediately after measuring which vital sign?

Answer 24

Pulse rate

Question 25

Blood pressure

Answer 25

is the force of the blood against the artery wall during contraction and relaxation of the ventricles.

Question 26

Monitoring the blood pressure helps the nurse identify problems with the patient’s

Answer 26

cardiac output, hydration, circulation, and arterial elasticity

Question 27

Systolic( top number)

Answer 27

the force exerted when the ventricles contracts.

Question 28

diastolic(bottom number)

Answer 28

The force exerted by peripheral vascular resistance when the ventricles are relaxed and the heart is filling.

Question 29

BP is at its highest and lowest at what times?

Answer 29

Blood pressure falls to its lowest point during diastole and is at its highest during systole

Question 30

What will happen to the patient's systolic they changes position from sitting to standing?

Answer 30

the systolic pressure will decrease slightly

Question 31

What will happen to the patient's diastolic they changes position from sitting to standing?

Answer 31

The diastolic pressure increases slightly

Question 32

Blood pressure below the normal range (less than 90 mmHg systolic or 60 mmHg diastolic) is classified

Answer 32

hypotension

Question 33

What can cause hypotension?

Answer 33

by dehydration, heart failure, and neurologic, cardiac, or endocrine disorders

Question 34

Orthostatic hypotension

Answer 34

the systolic pressure decreases by more than 20 mmHg or diastolic pressure decreases by more than 10 mmHg with position change from a lying or sitting position

Question 35

The nurse knows that the maximum systolic blood pressure considered normal is

Answer 35

119

Question 36

When measuring the blood pressure of a patient, which measurement represents the force exerted by peripheral vascular resistance when the heart is in the filling or relaxed state?

Answer 36

Diastolic pressure

Question 37

Which assessment method should be used to identify the systolic and diastolic blood pressure?

Answer 37

Auscultation

Question 38

What auscultatory landmark indicates the second diastolic sound?

Answer 38

Disappearance of Korotkoff sounds

Question 39

Pulse oximetry measures

Answer 39

the percentage of hemoglobin that is saturated with oxygen

Question 40

O2 sat

Answer 40

a measurement that tells the nurse how much oxygen is being carried in the blood as a percentage of the maximum it can carry

Question 41

Hypoxia

Answer 41

inadequate oxygen tension at the cellular level, characterized by tachycardia, hypertension, peripheral vasoconstriction, dizziness, and mental confusion

Question 42

The tissues most sensitive to hypoxia

Answer 42

are the brain, heart, pulmonary vessels, and liver

Question 43

To ensure an accurate reading of the pulse ox

Answer 43

the nurse should remove any nail polish from the fingernails or toenails. The patient should be instructed to stay still during the oximetry reading because movement can cause inaccuracies

Question 44

Why is it important to ensure a strong pulse during pulse oximetry testing?

Answer 44

essential that the site have a strong pulse because the pulse oximeter measures the change in the color of oxygenated and deoxygenated blood.

Question 45

A normal pulse oximetry reading falls within __ % to 100%?

Answer 45

95

Question 46

Which temperature, taken rectally, is outside the normal range for a healthy adult?

Answer 46

97° F

Question 47

An increase in body temperature may be an indication of which condition?

Answer 47

Infection, Damage to the hypothalamus, Vasoconstriction

Question 48

Contraction and relaxation of the skeletal muscles result in what temperature-regulating reaction?

Answer 48

Shivering

Question 49

The nurse is taking the pulse of an adult patient. Which description of pulse amplitude is characteristic of a normal pulse?

Answer 49

Strong

Question 50

Which findings relating to a patient’s pulse are considered normal?

Answer 50

regular rhythm, strong amp, contour with a smooth upstroke

Question 51

Which characteristics of respiration are normal findings?

Answer 51

Breathing with regular rhythm, breathing without effort, abdominal movements with breathing, and quiet breathing

Question 52

Which respiratory rate (in breaths per minute) would the nurse characterize as bradypnea?

Answer 52

9

Question 53

Blood pressure follows a diurnal pattern, peaking at what time during the day?

Answer 53

Afternoon

Question 54

What auscultatory landmark, identified after the systolic sound, marks the first diastolic sound?

Answer 54

Muffling of sounds

Question 55

The correct method for measuring blood pressure includes inflating the cuff to 20 to 30 mmHg above the palpable systolic pressure and then deflating at what speed to identify the systolic pressure reading?

Answer 55

2 to 3 mmHg/sec

Question 56

The pulse oximeter measures a patient’s blood oxygen based on which properties of hemoglobin?

Answer 56

Deoxygenated hemoglobin absorbs more red light than oxygenated hemoglobin.

Question 57

Which body areas are best for measuring the blood oxygen levels of an adult patient?

Answer 57

finger, toe, pinna

Question 58

The pulse oximetry reading indicates which physiologic measure?

Answer 58

How much oxygen the blood is carrying

Question 59

The level of BP is determined by the five factors

Answer 59

1. Cardiac output. If the heart pumps more blood into the container (i.e., the blood vessels), the pressure on the container walls increases. 2. Peripheral vascular resistance. Peripheral vascular resistance is the opposition to blood flow through the arteries. 3. Volume of circulating blood. Volume of circulating blood refers to how tightly the blood is packed into the arteries. 4. Viscosity. The “thickness” of blood is determined by its formed elements, the blood cells. When the contents are thicker, the pressure increases. 5. Elasticity of vessel walls.When the container walls are stiff and rigid, the pressure needed to push the contents increases.

Question 60

BP can be measured manually using

Answer 60

a sphygmomanometer