Vital Signs Chapter 19

Question 1

These allow the nurse to detect changes in the health status of the patient, identify early warning signs of life-threatening health conditions, and evaluate effectiveness of interventions.

Answer 1

Vital signs

Question 2

Vital signs consist of what 5 things?

Answer 2

Temperature, pulse, respirations, blood pressure, and pulse oximetry

Question 3

Vital sign: measurable heat of the human body. What is the normal range?

Answer 3

Temperature; 97.6-99.6

Question 4

Vital sign: detectable rhythmic expansion of an artery that occurs with the pumping action. What is the normal range?

Answer 4

Pulse; 60-100 BPM

Question 5

Vital sign: act of breathing measured in beats per minute. What is the normal range?

Answer 5

Respiration; 12-20 BPM

Question 6

Vital sign; the measurable pressure of blood within the systemic arteries. What is the normal range?

Answer 6

Blood pressure; systolic 90-120, diastolic 60-80.

Question 7

Vital sign; measures the amount of oxygen available to tissues. What is the normal range?

Answer 7

Pulse oximetry; 95%-100%

Question 8

Infection, physical environment, emotional state of patient, medications, fluid and food intake, activity level and tolerance are all factors that influence what?

Answer 8

Factors that influence vital signs.

Question 9

Age, exercise, hormone fluctuations, circadian rhythms, stress, environment, and smoking are all factors that influence what?

Answer 9

Factors that influence temperature.

Question 10

Condition of low body temperature. signs and symptoms include respirations, pale, cool skin, and decreased blood pressure.

Answer 10

Hypothermia

Question 11

Condition of high body temperature.

Answer 11

Hyperthermia

Question 12

This condition occurs when prolonged exposure to the sun or high environmental temperatures overwhelms the body’s heat loss mechanisms.

Answer 12

Heat stroke

Question 13

This condition occurs when extreme or prolonged environmental heat exposure leads to profuse sweating with consequent excessive water and electrolyte loss.

Answer 13

Heat exhaustion.

Question 14

What are the 5 common sites used to measure temperature?

Answer 14

Mouth, ear, rectum, forehead, axilla

Question 15

This selection is affected by patient’s age, state of consciousness, amount of pain the patient is suffering, and treatment the patient is undergoing.

Answer 15

Site selection of temperature

Question 16

Pulse is measured through which 9 areas? TCABRFPPtD

Answer 16

Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior tibial, Dorsalis pedis

Question 17

This pulse site is located at neck area and both should not be palpated at the same time because it could limit blood flow to the brain.

Answer 17

Carotid site

Question 18

This pulse site is located at the apex of the heart, at the fifth intercostal space midclavicular line. AKA Point of maximal impulse.

Answer 18

Apical pulse

Question 19

This pulse site is located at the inner aspect of the arm and used to assess pulse in pediatric emergencies

Answer 19

Brachial pulse

Question 20

This pulse site is located at femoral artery and used in cases of cardiac arrest and for assessing circulation to the leg.

Answer 20

Femoral pulse

Question 21

This pulse site is at medial surface of the ankle and used to determine circulation of the foot.

Answer 21

Posterior tibial pulse.

Question 22

This pulse site is used to determine circulation of the foot.

Answer 22

Dorsalis pedis pulse

Question 23

Listening with a stethoscope is considered what?

Answer 23

Auscultation

Question 24

An excessively fast heart rate of greater than 100 bpm

Answer 24

Tachycardia

Question 25

A slow heart rate of less than 60 bpm is called what?

Answer 25

Bradycardia

Question 26

Present when the patient's radial pulse rate is slower than the apical pulse because of cardiac contractions that are ineffective at pumping blood to the peripheral extremities.

Answer 26

Pulse deficit

Question 27

An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat.

Answer 27

Dysrhythmia or arrhythmia

Question 28

Normal respiration with a normal rate and depth for the patient's age

Answer 28

Eupnea

Question 29

An increase in respiratory rate of more than 24 BPM in the adult.

Answer 29

Tachypnea

Question 30

A decrease in respiratory rate to less than 10 BPM. Can be caused by medications, opioids, metabolic disorders, or brain injury.

Answer 30

Bradypnea

Question 31

Characterized by shallow respirations; associated with drug overdose and obesity, cervical spine injury, and COPD (chronic obstructive pulmonary disease).

Answer 31

Hypoventilation

Question 32

Characterized by deep, rapid respirations. Often caused by stress and anxiety.

Answer 32

Hyperventilation

Question 33

The absence of breathing; brain damage can occur after 4-6 minutes of this.

Answer 33

Apnea

Question 34

Shortness of breath or difficult, labored breathing with rapid shallow pattern.

Answer 34

Dyspnea

Question 35

Difficulty breathing when lying flat that is relieved by sitting or standing

Answer 35

Orthopnea

Question 36

The peak of blood pressure wave is called what? Where the heart contracts.

Answer 36

Systolic pressure

Question 37

The lowest pressure on arterial walls, which occurs when the heart rests is called what? Where the heart dilates.

Answer 37

Diastolic pressure

Question 38

Blood pressure is measured in what?

Answer 38

Millimeters of mercury (mm Hg)

Question 39

This condition is when systolic blood pressure is less than 90 mm Hg. Or 20-30 mm Hg below the patient's normal blood pressure.

Answer 39

Hypotension

Question 40

A sudden drop of 20 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the patient moves from lying to sitting to standing.

Answer 40

Orthostatic hypotension

Question 41

Elevated blood pressure that can lead to myocardial infarction, stroke, renal failure, and death.

Answer 41

Hypertension.

Question 42

The sounds in which the nurse listens to when assessing blood pressure.

Answer 42

Korotkoff sounds

Question 43

The absence of Korotkoff sounds noted in some patients after the initial systolic pressure. Failure to recognize this can cause major errors in measuring blood pressure.

Answer 43

Auscultatory gap

Question 44

Landmark for heart auscultation: located in 2nd intercostal space right of the sternal border.

Answer 44

Aortic valve

Question 45

Landmark for heart auscultation: located in 2nd intercostal space left of the sternal border.

Answer 45

Pulmonic valve

Question 46

Landmark for heart auscultation: located at 5th intercostal space left of the sternal border.

Answer 46

Tricuspid valve

Question 47

Landmark for heart auscultation: located at 3rd intercostal space, left of the sternal border.

Answer 47

Erb's point

Question 48

Landmark for heart auscultation: located at 5th intercostal space, mid clavicular line (apical pulse)

Answer 48

Mitral valve

Question 49

A condition that causes an increased lumbar curvature just above the buttocks area.

Answer 49

Lordosis

Question 50

An outward curvature of the thoracic spine.

Answer 50

Kyphosis

Question 51

A sideways or s-shaped curvature of the spine and is always abnormal.

Answer 51

Scoliosis