Vital Signs

Question 1

Define Heat Production

Answer 1

BMR
muscle activity (shivering & exercise)

Question 2

Normal body temperature

Answer 2

35.9-38C
96.7-100.5F

Question 3

Heat Loss

Answer 3

Evaporation
conduction
convection
radiation

Question 4

Most accurate measurements of body temperature are

Answer 4

intracranial
intrathoracic(esophagus/heart)
intra-abdominal(bladder)

Question 5

What route of obtaining body temperature is most accurate compared to oral, axillary, tympanic, and temporal arteries?

Answer 5

Rectal temperature is considered a core body temperature most accurate in comparison.

Question 6

Factors affecting body temperature

Answer 6

Circadian Rhythms
Age & Biological Sex
Physical Activity
State of Health
Environmental Temperature.

Question 7

Fever (Pyrexia)

Answer 7

is an increased above normal body temperature. A patient with a fever is said to be febrile.

Question 8

Benefits of fever

Answer 8

Unless extremely high >40C/104F
Benefits include destruction/susceptibility of disease-causing microorganisms, enhanced immune response

Question 9

Fever is caused by

Answer 9

triggered by microorganisms, tissue injury (myocardia infraction), and surgery.

Question 10

SIgns and symptoms of fever

Answer 10

loss of appetite (anorexia), headache, hot/dry skin, flushed face, thirst, muscle aches, fatigue, increase pulse and respiration.

Question 11

Treatment of fever

Answer 11

appropriate antibiotic, antipyretic, use of cool sponge baths, cool packs, cooling blankets, fluids, and simple carbohydrates.

Question 12

Hyperthermia

Answer 12

caused by extreme heat exposure.

Question 13

Neurogenic Fever

Answer 13

caused by increased intracranial pressure/intracranial bleeding
Does not respond to anti-pyretic

Question 14

Fever of Unknown Orgin (FUO)

Answer 14

a type of fever (>38.3 C/101F) that lasts for 3 weeks or longer without an identified cause.

Question 15

Pulse

Answer 15

a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle. It is regulated by the autonomic nervous system.

Question 16

Normal pulse range

Answer 16

60-100 beats/min

Question 17

Tachycardia

Answer 17

pulse rate above 100

Question 18

Bradycardia

Answer 18

pulse rate below 60

Question 19

Dysrhythm

Answer 19

an irregular rhythm

Question 20

Factors affecting pulse rate

Answer 20

age & biological sex
physical activity
body temperature/stress
medication
disease

Question 21

Reasons for lower temperature in older adults

Answer 21

decreased metabolic rate
reduced subcutaneous fat
diminished hypothalamic regulation
impaired thermoregulation

Question 22

What is a pulse defecit

Answer 22

occurs when there is a difference between the heartbeats (measured at the apical pulse) and the peripheral pulses( eg radial pulse). Not all heartbeats are strong enough to create a palpable pule wave at a peripheral artery, indicating that the heart is contracting but not all contractions are producing effective blood flow.

Question 23

How to assess Pulse Defecit

Answer 23

One nurse listens to the apical pulse while another simultaneously palpates the radial pulse.
Both counts are taken for one full minute
the difference between the two is the pulse defecit

Question 24

Significance of pulse defecit in nursing practice

Answer 24

indicator of arrhythmias
evaluation of cardiac function
guiding treatment
monitoring patient condition

Question 25

Respirations

Answer 25

the movement of gases in and out of the lungs. Also called ventilation or in layman's terms, breathing. It is regulated by the autonomic nervous system and voluntary control.

Question 26

Normal Respiration range

Answer 26

12-2o breaths/min.

Question 27

Tachypnea

Answer 27

above 24 respirations/min

Question 28

Bradypnea

Answer 28

below 10 respirations/min

Question 29

Cheyne-Stokes/Biot's respiration

Answer 29

irregular respiration

Question 30

Eupnea

Answer 30

normal unlabored respirations

Question 31

Hyperventilation (Kissmaul's breathing)

Answer 31

increased in rate and depth of respirations

Question 32

Apnea

Answer 32

absence of breathing

Question 33

Dyspnea

Answer 33

difficulty breathingo

Question 34

orthopenia

Answer 34

difficulty breathing that occurs when supine position and is relieved upon changing to a high fowlers position.

Question 35

Factors affecting respiratory rate

Answer 35

age, exercise, acid-base balance, brain lesions, increased altitude, respiratory diseases, anemia, anxiety, medication, acute pain

Question 36

Pulse oximeter

Answer 36

measures the amount of oxygen in the blood. Normal range is 90-100%

Question 37

Blood Pressure

Answer 37

force of moving blood against the arterial wall. The numerator is the systolic, denominator is the diastolic.

Question 38

Pulse Pressure

Answer 38

the difference between the systolic pressure and the diastolic pressure. It reflects the force that the heart generates with each contraction.

Question 39

Mean Arterial Pressure (MAP)

Answer 39

the average pressure in a person's arteries during one cardiac cycle. It gives an indication of overall perfusion to the organs.

Question 40

Calculate Mean Arterial Pressure

Answer 40

MAP=DBP +1/3 X (SBP-DBP)

Question 41

Normal Pulse Pressure

Answer 41

30-40 mmHg

Question 42

Widened Pulse PRessure

Answer 42

>60 mmHg may indicate stiffening of the arteries or atherosclerosis, which is common in older adults and increases the risk of cardiovascular events like stroke and heart failure.

Question 43

Narrowed Pulse Pressure

Answer 43

< 25 mmHg can indicate heart failure, shock, or aortic stenosis. It often reflects poor stroke volume and may require immediate clinical intervention.

Question 44

Clinical significance of pulse pressure

Answer 44

high= early sign of hypertension or cardiac disease low= sign of left ventricular dysfunction or a compensatory mechanism during shock.

Question 45

Mean Arterial Pressure

Answer 45

normal 70-100 mmHg <60 mmHg indicated inadequate organ perfusion >100 mmHg suggests hypertention

Question 46

Normal Blood Pressure

Answer 46

<120/<80 mmHg

Question 47

Hypertension

Answer 47

>130/>80

Question 48

Hypotension

Answer 48

<90/60

Question 49

Orthostatic hypotension is

Answer 49

decrease is systolic > or equal to 20mmHg or decrease in diastolic >or equal to 10 mmHg when one rises to an erect position. Common among elderly related to underlying disease process, dehydration, or use of medications.

Question 50

Factors that affect blood pressure

Answer 50

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

Question 51

Auscultatory gap

Answer 51

In hypertensive clients, there is a wide gap (silence) of as much as 40 mmHg between the 1st and 2nd Korotkoff sound.