Unit 2: Chapter 29 Vital Signs Flashcards
(21 cards)
Ms. Lewis is admitted with fatigue and confusion. You are assigned to perform a full set of vital signs and assess her cardiovascular and respiratory status.
.
Which temperature would be classified as a fever in an adult?
A. 36.9°C (98.4°F)
B. 37.2°C (99.0°F)
C. 38.3°C (100.9°F)
D. 37.0°C (98.6°F)
C
ever is ≥38°C.
Match the temperature regulation mechanism with its primary function:
Mechanism Function
Anterior hypothalamus ☐ Promotes heat loss
Posterior hypothalamus ☐ Promotes heat production
Conduction ☐ Transfer of heat via direct contact
Evaporation ☐ Heat loss through vaporization
Anterior = heat loss, Posterior = heat production, Conduction = direct contact, Evaporation = vaporization.
The most reliable core temperature site in critical care is the:
[ Select ]
Options:
Tympanic membrane
Pulmonary artery
Temporal artery
Rectum
Pulmonary artery — Most accurate core site.
Which factors can lead to false-high blood pressure readings? (Select all that apply)
A. Cuff wrapped too loosely
B. Arm above heart level
C. Repeated assessments too quickly
D. Cuff too wide
E. Patient anxiety
A, C, E
Loose cuff, rapid repetition, and anxiety elevate BP.
Match each pulse characteristic with its clinical significance:
Characteristic Significance
Bradycardia ☐ Pulse < 60 bpm
Tachycardia ☐ Pulse > 100 bpm
Weak, thready pulse ☐ Low cardiac output
Bounding pulse ☐ High stroke volume
Bradycardia = <60 bpm, Tachycardia = >100 bpm, Weak = low output, Bounding = high volume.
Put the steps for assessing a patient’s radial pulse in the correct order:
☐ Palpate radial artery
☐ Assess rate, rhythm, and strength
☐ Count for 30 seconds if regular
☐ Multiply by 2 to calculate bpm
Palpate → Assess → Count → Multiply
Which site should be used to assess pulse when cardiac output is rapidly declining?
A. Brachial
B. Radial
C. Carotid
D. Popliteal
C
Carotid is fastest in emergency.
A respiratory rate below 12 breaths/min in an adult is classified as ________.
Bradypnea
Match the altered respiratory patterns with their description:
Pattern Description
Cheyne-Stokes ☐ Cycles of apnea and hyperventilation
Kussmaul’s ☐ Deep, labored, fast breathing
Biot’s ☐ Shallow breaths with irregular apnea
Tachypnea ☐ Rapid, regular breathing
Cheyne-Stokes = cycle apnea/hyper, Kussmaul = deep/labored, Biot = shallow/irregular, Tachypnea = fast
Pulse oximetry values below [ Select ]% indicate that tissues may not be receiving adequate oxygen.
Options:
100
95
92
75
92
Lower may impair oxygenation.
Which patient factors can interfere with pulse oximetry readings? (Select all that apply)
A. Dark nail polish
B. Poor perfusion
C. Skin moisture
D. Jaundice
E. Elevated temperature
A, B, C, D
All but temperature interfere.
Match each blood pressure term with its meaning:
Term Definition
Systolic pressure ☐ Pressure during heart contraction
Diastolic pressure ☐ Pressure during heart relaxation
Pulse pressure ☐ Difference between systolic and diastolic
MAP ☐ Average pressure in arteries during one cycle
Systolic = contraction, Diastolic = relaxation, Pulse pressure = difference, MAP = average pressure
Which BP reading qualifies as Hypertension Stage 1?
A. 120/80 mm Hg
B. 124/76 mm Hg
C. 130/88 mm Hg
D. 142/92 mm Hg
C
130–139 or 80–89 = Stage 1
Which interventions are appropriate for managing a febrile patient? (Select all that apply)
A. Reduce activity
B. Apply multiple blankets
C. Administer oxygen as ordered
D. Monitor temperature trends
E. Withhold fluids
A, C, D
Reduce demand, hydrate, oxygenate
Match the temperature measurement site with an advantage or limitation:
Site Consideration
Oral ☐ Affected by hot/cold fluid intake
Tympanic membrane ☐ Quick, but variable if not positioned well
Temporal artery ☐ Noninvasive but affected by sweat/hair
Rectal ☐ Closest to core, but invasive
Oral = fluid interference, Tympanic = positioning, Temporal = sweat/hair, Rectal = invasive
To visualize the thyroid during assessment, ask the patient to:
[ Select ]
Options:
Swallow
Cough
Yawn
Puff cheeks
Swallow — Helps visualize thyroid.
Multiple Choice
In older adults, the most common change in blood pressure is:
A. Decreased systolic, stable diastolic
B. Increased systolic, stable diastolic
C. Decreased systolic and diastolic
D. Stable systolic and diastolic
B
Common in aging: widened pulse pressure
Put the following respiratory assessment steps in order:
☐ Position patient with head elevated
☐ Observe chest for rise and fall
☐ Count respirations for 30 seconds
☐ Evaluate rhythm and depth
Elevate → Observe → Count → Evaluate
Match each BP method with its characteristic:
Method Characteristic
Auscultatory ☐ Uses stethoscope and Korotkoff sounds
Oscillometric ☐ Automated, detects vibrations
Palpation ☐ Estimates systolic only
Doppler ☐ Used when pulses are hard to hear or feel
Auscultatory = stethoscope, Oscillometric = automated, Palpation = systolic only, Doppler = low sound volume
Which are nursing responsibilities when measuring vital signs? (Select all that apply)
A. Interpret abnormal findings
B. Record values in chart
C. Diagnose the medical problem
D. Decide when to reassess
E. Clean reusable equipment
A, B, D, E
Nurses assess and report, not diagnose
