Vital Signs

Question 1

What are the 5 vital signs

Answer 1

Temp
Pulse
Resp
Blood Pressure
Pain

Question 2

Normal Blood Pressure

Answer 2

120/80

Question 3

Normal Temp Range

Answer 3

96.4 - 99.5

Question 4

Normal Respirations Range

Answer 4

12-20 breaths per minute

Question 5

Normal Pluse Range

Answer 5

60-100 beats per minute

Question 6

LOC

Answer 6

Level Of Consiousness

Question 7

When to asses vitals

Answer 7

admission
change in condition
change in LOC
before and after an invasive prodcedure
before and after activites that may cause change
before meds
per facility policy

Question 8

Factors affecting body temp

Answer 8

Age
menopause
pregnancy
time of day
physical activity
overall health

Question 9

What temp is does a fever start at

Answer 9

100.5

Question 10

What is hyperthermia
causes
benefits

Answer 10

increase above normal body temp
causes; illness, cancer, trauma, surgery
benefits; start immune system, inital something is wrong

Question 11

S & SX (signs and symptoms) of Hyperthermia

Answer 11

confusion&delerium (older patient)
fatigue
flushed face
hot, dry skin
increased pulse and resp rate
loss of appetite
muscle aches
shivering
thirst

Question 12

Hyperthermia treatment
priority
pharmacological
nonpharmacological

Answer 12

Priority; treat the cause
pharmacological; antipyretics(NSAIDS/Acetaminophen)
nonpharmacological; cool sponge baths, increase fluid intake

Question 13

What is hypothermia
-causes

Answer 13

decrease in temperature below the lower limit of normal
causes; exposure to cold, chronic conditions, perioperative clients, new born babies

Question 14

S & SX (signs and symptoms) of hypothermia

Answer 14

poor coordination
slurred speech
poor judgement
amnesia
hallucinations
vital sign decrease

Question 15

Hypothermia treatment

Answer 15

rewarming
with a warming blanket, warm fluids, and/or additonal clothing/blankets

Question 16

Temperature routes

Answer 16

sublingual
tympanic
temporal
rectal
axillary

Question 17

Advantages and contraindications of sublingual temp

Answer 17

advantages;
most common
easily acessible
contraindications:
intake of hot/cold fluids or food
smoking
chewing gum

Question 18

advantages and contraindications of tympanic temp

Answer 18

advantages;
easily accessible
contraindications;
drainage in ear
ear pain
ear infection
scars on tympanic membrane

Question 19

advantages and contraindications of temporal temp

Answer 19

advantages;
more accurate than axillary
contraindications;
forehead coverings
affected by external temps

Question 20

advantages and contraindications of rectal temp

Answer 20

advantages;
most accurate
contraindications;
special thermometer
heart disease or surgery (vagual stim. can cause heart rate to bottom)
neutropenic precautions
low platelet count
spinal cord injuries

Question 21

advantages and contraindications for axillary temp

Answer 21

advantages;
use when sublingual and rectal sites are contraindicated or not acessible
contraindications;
least accurate of them all
unable to keep arm down until reading is complete

Question 22

pulse characteristics

Answer 22

rate
rhythm (regualr or irregular)
amplitude (strength)
bradycardia (-60)
tachycardia (+100)

Question 23

factors affecting pulse rates

Answer 23

age
biological sex
fever
medication use
physical activity
presence of disease
stress

athletes have a lower heart rate, stress/anxiety have higher heart rate

Question 24

pulse location

Answer 24

temporal
carotid
apical (PMI pulse, between 4&5 rib)
brachial
radial
femoral
popliteal
post. tibia artery
pedal

Question 25

tachycardia rate causes

Answer 25

fast heart rate between 100-180 bpm causes; drugs fever hypotensive low oxygen blood pain stress

Question 26

bradycardia rate causes

Answer 26

below 60 bpm causes; decreased body temp deleruim heart attack hypothyroidism intracranial pressure medications sleep sleep apnea vagal stimulation

Question 27

pulse amplitude how its measured

Answer 27

the quality or fullness of the sound meausured by grades 0-absent, unable to palpate +1 - deminished, weaker than expected +2 - brisk, expected +3 - bounding

Question 28

respiration characteristics

Answer 28

rhythm - reg or irreg depth- force of inhalation/exhalation

Question 29

factors affecting respiration

Answer 29

acid-base balance acute pain age anemia anxiety brain lesions exercise increased altitude medications respiratory disease

Question 30

respiration rhythms

Answer 30

apnea - without resporations tachypnea - rate greater than 24 breaths per min bradypnea - rates less than 10 breaths per min

Question 31

respiration rates

Answer 31

normal - 12-20 breath/min tachypnea - >24 bpm bradypnea - <10 bpm hyperventilation - increased rate and depth hypoventilation - decreased rate and depth cheyne-stokes - alternating periods of deep rapid breathing, followed by periods of apnea (regular) Biots resp - varying depth and rate of breathing followed by periods of apnea (irregualr)

Question 32

pulse oximetry range false reading causes

Answer 32

measures the % of oxygen saturation in the blood range; 95% - 100% false reading causes; cold hands wrong location equipment malfunction fingernail polish/acrylic

Question 33

Blood pressure top number | name

Answer 33

systolic

Question 34

Blood Pressure bottom number | name

Answer 34

diastolic

Question 35

blood pressure ranges

Answer 35

normal; < 120/80 elevated; 120-129/80 hypotension; below 90/60 hypertensive stage 1; 130-139/80-89 hypertensive stage 2; >140/>90 hypertensive crisis; >180/>120

Question 36

factors affecting blood pressure

Answer 36

age biological sex body position circadian rhythm drugs/medications emotional state exercise food intake race weight

Question 37

factors causing false low blood pressure readings

Answer 37

hearing deficit noise in enviornment applying cuff thats too wide inserting stethoscope in ears incorrectly releasing valve too fast

Question 38

factors causing false high blood pressure readings

Answer 38

incorrectly calibrated manometer applying cuff that is too narrow releasing valve too slow reinflating bladder during ausculatation

Question 39

hypertension at risk?

Answer 39

over 130/80 at risk? family hx (history) race sleep apnea diabetes cholesterol african american males

Question 40

hypotension

Answer 40

less than 90/60

Question 41

orthostatic hypotension preventions

Answer 41

rapid movement of sitting to standing, gets dizzy let patient dangle and get up slowly

Question 42

oxygentation

Answer 42

amount of oxygen in the blood

Question 43

perfusion

Answer 43

volume of blood