General Health Status & Vital Signs

Question 1

The ??? is the first part of the physical examination that begins the moment the nurse meets the client.

Answer 1

general survey

Question 2

the body’s indicators of health

Answer 2

vital signs

Question 3

In 2001, The Joint Commission designated “???” the “fifth vital sign” because of its chronic undertreatment

Answer 3

pain

Question 4

is inexpensive to assess and does not involve the use of fancy instruments, yet it can be an early predictor of impending disability.

Answer 4

Pain

Question 5

It is a good idea to begin the “hands-on” physical examination by ???

Answer 5

taking vital signs

Question 6

For the body to function at a cellular level, a core body temperature between ??? and ???(96.0°F and 99.9°F orally) must be maintained

Answer 6

36.5°C and 37.7°C

Question 7

Strenuous exercise, stress, and ovulation can ??? temperature

Answer 7

raise

Question 8

Body temperature is ??? early in the morning (4:00–6:00 AM)

Answer 8

lowest

Question 9

Body temperature is ??? late in the evening (8:00 PM to midnight).

Answer 9

highest

Question 10

??? may be seen in prolonged exposure to the cold, hypoglycemia, hypothyroidism, or starvation.

Answer 10

Hypothermia

Question 11

Hypothermia temperature

Answer 11

(<36.5°C or 96.0°F)

Question 12

may be seen in viral or bacterial infections, malignancies, trauma, and various blood, endocrine, and immune disorders.

Answer 12

Hyperthermia

Question 13

Hyperthermia temperature

Answer 13

(>38.0°C or 100°F)

Question 14

A shock wave is produced when the heart contracts and forcefully pumps blood out of the ventricles into the aorta. The shock wave travels along the fibers of the arteries and is commonly called the ??? or ???

Answer 14

arterial or peripheral pulse

Question 15

pulse amplitude: 0

Answer 15

absent

Question 16

pulse amplitude: 1+

Answer 16

weak, diminished (easy to obliterate)

Question 17

pulse amplitude: 2+

Answer 17

normal, obliterate with moderate pressure

Question 18

pulse amplitude: 3+

Answer 18

bounding, unable to obliterate/requires firm pressure

Question 19

reflects the pressure exerted on the walls of the arteries

Answer 19

Blood pressure

Question 20

BP: varies with the cardiac cycle, reaching a high point with ??? and a low point with ???

Answer 20

systole;
diastole

Question 21

Factor (BP): The more blood the heart pumps, the greater the pressure in the blood vessels.

Answer 21

Cardiac Output

Question 22

Factor (BP):
An increase in resistance in the peripheral vascular system, as happens with people who have circulatory disorders, will increase blood pressure.

Answer 22

Peripheral Vascular Resistance

Question 23

Factor (BP): An increase in volume will increase blood pressure. A sudden drop in blood pressure may indicate a sudden blood loss, as with internal bleeding

Answer 23

Circulating Blood Volume

Question 24

Factor (BP):
When the blood becomes thicker or more viscous (as with polycythemia), the pressure in the blood vessels will increase

Answer 24

viscosity

Question 25

Factor (BP): An increase in stiffness of the vessel walls (e.g., atherosclerotic changes) will increase blood pressure.

Answer 25

Elasticity of Vessel Walls

Question 26

The difference between systolic and diastolic pressure is termed the ???

Answer 26

pulse pressure

Question 27

Pain quality may be described as (4)

Answer 27

dull, sharp, radiating, or throbbing

Question 28

A pattern of elevated temperatures may indicate a ??? such as tuberculosis or ??? such as leukemia.

Answer 28

chronic infection; blood disorder

Question 29

An alteration in heartbeat felt by a client is called a “???” and can be caused by various circumstances,

Answer 29

palpitation

Question 30

Although older adults generally have the same normal temperature range as younger adults, older adults have ???, so have trouble maintaining that normal temperature, thereby often feeling cold

Answer 30

lower metabolisms

Question 31

The tympanic membrane temperature is normally about ???than the normal oral temperature

Answer 31

0.8°C (1.4°F) higher

Question 32

Oral temperature is ??? to ???

Answer 32

35.9°C (96.6°F) to 37.5°C (99.5°F)

Question 33

The axillary temperature is ??? than the oral temperature

Answer 33

0.5°C (1°F) lower

Question 34

Normal axillary temperature range is ???

Answer 34

35.4°C–37.0°C (95.6°F - 98.5°F)

Question 35

The temporal artery temperature is approximately ??? than axillary

Answer 35

0.4°C (0.8°F) higher

Question 36

Normal temporal artery temperature range is

Answer 36

36.3°C–37.9°C (97.4°F-100.3°F)

Question 37

A ??? is a noninvasive device that the operator sweeps from the center of the forehead to a point behind the ear.

Answer 37

temporal artery thermometry

Question 38

The most accurate temperature is the ???, which is not practical to measure because it is an invasive method

Answer 38

core pulmonary artery temperature

Question 39

The rectal temperature is ??? than the normal oral temperature

Answer 39

between 0.4°C and 0.5°C (0.7°F and 1°F) higher

Question 40

Normal rectal temperature range is ???

Answer 40

36.3°C–37.9°C (97.4°F-100.3°F).

Question 41

is a rate >100 beats/min. May occur with fever, certain medications, stress, and other abnormal states, such as cardiac dysrhythmias

Answer 41

Tachycardia

Question 42

is a rate <60 beats/min. Sitting or standing for long periods may cause the blood to pool and decrease the pulse rate. Heart block or dropped beats can also manifest as this.

Answer 42

Bradycardia

Question 43

The ??? client’s artery may feel more rigid, hard, and bent.

Answer 43

older

Question 44

older adult RR range

Answer 44

15-22

Question 45

Respirations <8–12 breaths/min (???) may indicate sedation, increased intracranial pressure, or neurologic disorders.

Answer 45

bradypnea

Question 46

results from slow shallow breaths that may be seen with sedation or increased intracranial pressure.

Answer 46

Hypoventilation

Question 47

is the absence of respiration for >10 seconds.

Answer 47

Apnea

Question 48

Respirations >24 breaths/min (???) are seen with exercise, fever,

Answer 48

tachypnea

Question 49

is rapid deep breaths that may be seen with metabolic acidosis, hypoxia, anxiety, or exercise.

Answer 49

Hyperventilation

Question 50

describes difficult or labored respirations.

Answer 50

Dyspnea

Question 51

SPO2 <92% (???), unless with chronic obstructive pulmonary disease, and >99%, which is ???.

Answer 51

hypoxia; hyperoxemia

Question 52

Widening of the pulse pressure is seen with ??? due to less elastic peripheral arteries.

Answer 52

aging