Measurements and Vital Signs

Question 1

What are the FOUR main vital signs?

Answer 1

1. Temperature
2. Pulse
3. Respirations
4. Blood pressure

These indicators help assess overall health status.

Question 2

How is body temperature measured?

Answer 2

• Orally
• Rectally
• Axillary, tympanic (ear)

Different sites have varying normal temperature ranges.

Question 3

List TWO factors that can affect temperature readings.

Answer 3

1. Activity level
2. Time of day

Fever and hypothermia indicate abnormal body temperatures.

Question 4

Fill in the blanks:

A normal oral temperature range is ____ to ____ °F.

Answer 4

97.6; 99.6

Normal temperature varies by measurement site.

Question 5

True or False:

Rectal temperature is usually lower than oral temperature.

Answer 5

False

Rectal temperature is slightly higher than oral temperature.

Question 6

Define:

hypothermia

Answer 6

A body temperature below the normal range.

Hypothermia can be life-threatening if not treated.

Question 7

Define:

a fever

Answer 7

A temperature above the normal range.

Fevers are usually caused by infection.

Some fevers resolve naturally, but high fevers need treatment.

Question 8

Which vital sign measures the heart rate?

Answer 8

Pulse

Pulse is counted in beats per minute (bpm).

Question 9

List TWO ways of taking pulse measurements.

Answer 9

1. By palpating an artery.
2. Using a stethoscope.

Common pulse sites include radial and apical.

Question 10

Which pulse site is most commonly used?

Answer 10

The radial pulse (wrist).

It is easy to access and measure accurately.

Question 11

What is the normal pulse range for adults?

Answer 11

60-100 beats per minute.

A pulse above or below this range may indicate a health issue.

Question 12

How long should a pulse be counted?

Answer 12

For one full minute.

This ensures accuracy and detects irregularities.

Question 13

Fill in the blank:

A pulse over 100 beats per minute is called _______.

Answer 13

Tachycardia

Tachycardia can be caused by stress, fever, or heart conditions.

Question 14

What is the most accurate way to measure pulse in infants?

Answer 14

Apical pulse (using a stethoscope).

Infants’ pulses are faster and harder to detect peripherally.

Question 15

True or False:

A weak pulse is always normal.

Answer 15

False

A weak or thready pulse may indicate heart problems or poor circulation.

It should be reported to the nurse immediately.

Question 16

What does a rapid, thready pulse indicate?

Answer 16

• Possible shock
• Blood loss

Requires immediate medical attention.

Question 17

Define:

respiration rate

Answer 17

The number of breaths taken per minute.

It includes one inhalation and one exhalation.

Question 18

What is the normal adult respiratory rate?

Answer 18

15-20 breaths per minute.

Fast or slow breathing may indicate health problems.

Question 19

How can respirations be measured discreetly?

Answer 19

By observing chest movement while pretending to check the pulse.

Some patients change their breathing if they know it’s being monitored.

Question 20

List THREE factors that can increase respiration rate?

Answer 20

1. Fever
2. Anxiety
3. Pain

High respiratory rate may indicate distress or illness.

Question 21

What is considered a dangerously low respiratory rate?

Answer 21

Below 10 breaths per minute.

Can indicate respiratory failure or drug overdose.

Question 22

What does blood pressure measure?

Answer 22

The force of blood against artery walls.

Blood pressure readings include systolic and diastolic values.

Question 23

What is a normal blood pressure range?

Answer 23

90/60 to 120/80 mmHg

Consistently high readings indicate hypertension while low readings indicate hypotension.

Question 24

Fill in the blank:

The first number in a blood pressure reading is the ______ pressure.

Answer 24

systolic

It measures pressure when the heart contracts.

The second number is the diastolic pressure; the pressure of the blood against the walls when the heart relaxes.

Question 25

List THREE signs of **low blood pressure**.

Answer 25

1. Dizziness 1. Fainting 1. Shock ## Footnote Low blood pressure can be due to medications, bleeding, infection, heart failure, or dehydration.

Question 26

Which **position** is best for taking blood pressure?

Answer 26

**Seated** with feet flat on the floor. ## Footnote Ensures accurate readings and patient comfort.

Question 27

What is **orthostatic** hypotension?

Answer 27

A drop in blood pressure **when standing up**. ## Footnote Common in elderly patients, leading to dizziness and falls.

Question 28

What should be done **before measuring** blood pressure?

Answer 28

Allow the patient to **rest for five minutes**. ## Footnote Activity can temporarily raise blood pressure readings.

Question 29

What should be **observed** when checking skin integrity?

Answer 29

* Color * Moisture * Temperature * Presence of wounds ## Footnote Changes in skin condition should be reported immediately.

Question 30

What can cause **poor skin integrity**?

Answer 30

* Pressure ulcers * Friction * Shearing ## Footnote Preventive care includes repositioning and moisturizing.

Question 31

What is the purpose of a **weight measurement**?

Answer 31

To **monitor health status** and detect changes. ## Footnote Sudden weight loss or gain may indicate a health problem.

Question 32

How **often** should **weight be measured** in a hospital?

Answer 32

As ordered by the physician. ## Footnote Daily weight is important for conditions like heart failure.

Question 33

How should weight be measured **accurately**?

Answer 33

Using the **same scale** at the **same time** of day. ## Footnote Consistency ensures accuracy and reliability. Heavy clothing should also be removed since extra weight from clothing can give an inaccurate readings.

Question 34

# Fill in the blank: Weight should be measured in \_\_\_\_\_\_ **units**.

Answer 34

pounds or kilograms ## Footnote The unit depends on facility standards.

Question 35

How should a patient’s **height be measured**?

Answer 35

Standing **upright** against a measuring device. ## Footnote If bedridden, height can be measured using a tape measure.

Question 36

Which vital sign is affected by **dehydration**?

Answer 36

Blood pressure ## Footnote Dehydration can cause hypotension and dizziness.

Question 37

How can **hydration status** be assessed?

Answer 37

**By checking**: 1. urine color 1. skin elasticity ## Footnote Dark urine and dry skin indicate dehydration. A well-hydrated person’s urine is usually light yelow in color.

Question 38

# True or False: Poor hydration can lead to confusion **in older adults**.

Answer 38

True ## Footnote Dehydration affects cognitive function, especially in seniors.

Question 39

What factors can affect **circulation**?

Answer 39

* Blood pressure * Heart function * Activity level ## Footnote Poor circulation can lead to complications like swelling and ulcers.

Question 40

How can **mobility** affect vital signs?

Answer 40

Inactivity can lead to **poor circulation** and **weak muscles**. ## Footnote Exercise promotes heart health and stable vital signs. Caregivers can assist patients with limited mobility through regular repositioning and assisting with transfers.

Question 41

# Define: auscultation

Answer 41

Listening to **internal body sounds** with a stethoscope. ## Footnote Used for heart, lung, and bowel sounds.

Question 42

How can **stress** affect vital signs?

Answer 42

It can **raise** heart rate and blood pressure. ## Footnote Relaxation techniques help manage stress-related symptoms.

Question 43

Why should vital signs be **recorded accurately**?

Answer 43

They **guide medical decisions** and treatment. ## Footnote Errors in recording can lead to incorrect care.

Question 44

What should be done if **vital signs** are **abnormal**?

Answer 44

* Report immediately * Recheck if necessary ## Footnote Prompt reporting ensures timely intervention.

Question 45

How should caregivers ensure **patient comfort** during vital sign checks?

Answer 45

1. Explain procedures 1. Maintain privacy 1. Be gentle ## Footnote Patients may feel anxious or uncomfortable during checks.