VITAL SIGNS II Flashcards
(103 cards)
1
Q
- The fundamental measurements of the body’s essential functions, including temperature, pulse, respiration, and blood pressure.
A
Vital Signs
2
Q
- When should vital signs be assessed?
A
- On admission
- Before and after surgery
- During medication administration
- When there is a change in condition
- According to hospital policy
3
Q
- What are the normal body temperature ranges?
A
- Celsius: 36.0 – 37.5°C
- Fahrenheit: 96.8 – 99.5°F
4
Q
- What are the methods of measuring body temperature?
A
- Oral
- Rectal
- Axillary
- Tympanic
- Temporal
5
Q
- What is oral temperature?
A
A temperature reading taken by placing a thermometer under the tongue.
6
Q
- What is rectal temperature?
A
A temperature reading taken by inserting a thermometer into the rectum, considered the most accurate core temperature measurement.
7
Q
- What is axillary temperature?
A
A temperature reading taken in the armpit, considered the least accurate method.
8
Q
- What is tympanic temperature?
A
A temperature reading taken inside the ear canal using an infrared thermometer.
9
Q
- What is temporal temperature?
A
A temperature reading taken by scanning the forehead, using infrared technology.
10
Q
- What are the phases of fever?
A
- Onset (Cold or Chill Phase)
- Course (Plateau Phase)
- Defervescence (Fever Abatement Phase)
11
Q
- What is the Onset (Cold or Chill Phase) of fever?
A
The phase where the patient experiences chills, shivering, and a cessation of sweating.
12
Q
- What is the Course (Plateau Phase) of fever?
A
The phase when the body temperature is at its highest point.
13
Q
- What is the Defervescence (Fever Abatement Phase) of fever?
A
The phase characterized by sweating, flushed skin, and a decrease in body temperature.
14
Q
- What are the different fever patterns?
A
- Remittent Fever
- Relapsing Fever
- Intermittent Fever
- Continuous Fever
15
Q
- What is a Remittent Fever?
A
A fever pattern where the temperature fluctuates but never returns to normal.
16
Q
- What is a Relapsing Fever?
A
A fever pattern where the temperature remains above normal with normal temperature periods between spikes.
17
Q
- What is an Intermittent Fever?
A
A fever pattern where the temperature rises and falls but returns to normal in between spikes.
18
Q
- What is a Continuous Fever?
A
A fever that remains consistently elevated and does not fluctuate significantly.
19
Q
- What are the types of pulse rates?
A
- Normal
- Tachycardia
- Bradycardia
20
Q
- What is a normal pulse rate for adults?
A
60 – 100 beats per minute (bpm).
21
Q
- What is tachycardia?
A
A pulse rate greater than 100 bpm in adults.
22
Q
- What is bradycardia?
A
A pulse rate lower than 60 bpm in adults.
23
Q
- What is pulse amplitude?
A
The strength of a pulse, which can be graded using a scale from 0 to 4+.
24
Q
- What are the pulse grading levels?
A
- 0 (Absent)
- 1+ (Thready)
- 2+ (Weak)
- 3+ (Normal)
- 4+ (Bounding)
25
25. What is an absent pulse (0)?
A pulse that is not palpable.
26
26. What is a thready pulse (1+)?
A weak, barely palpable pulse that disappears with slight pressure.
27
27. What is a weak pulse (2+)?
A pulse that is easily palpable but slightly diminished.
28
28. What is a normal pulse (3+)?
A strong, easily palpable pulse with normal force.
29
29. What is a bounding pulse (4+)?
A full, forceful pulse that does not disappear with pressure.
30
30. What are the types of pulse rhythms?
- Regular
- Irregular
- Intermittent
- Bigeminal
- Paradoxical Pulse
31
31. What is an intermittent pulse?
A pulse where occasional beats are skipped or absent, occurring at irregular intervals.
32
32. What is a bigeminal pulse?
A pulse rhythm where every normal beat is followed by a premature beat.
33
33. What is a paradoxical pulse?
A pulse that decreases in strength during inhalation and increases during exhalation, often seen in pericardial effusion.
34
34. What are the normal respiratory rates for adults?
12 – 20 breaths per minute
35
35. What are the abnormal respiratory patterns?
- Tachypnea
- Bradypnea
- Apnea
- Kussmaul’s Respiration
- Cheyne-Stokes Respiration
- Orthopnea
36
36. What is tachypnea?
A respiratory rate higher than 20 breaths per minute.
37
37. What is bradypnea?
A respiratory rate lower than 12 breaths per minute.
38
38. What is apnea?
A condition in which breathing temporarily stops.
39
39. What is Kussmaul’s Respiration?
Deep, rapid breathing associated with metabolic acidosis.
40
40. What is Cheyne-Stokes Respiration?
Breathing characterized by cycles of deep breathing followed by apnea.
41
41. What is orthopnea?
Difficulty breathing that requires the patient to sit upright for comfort.
42
42. What are the normal blood pressure values for adults?
120/80 mmHg
43
43. What is systolic pressure?
The peak pressure exerted when the ventricles contract.
44
44. What is diastolic pressure?
The lower pressure when the heart is at rest between beats.
45
45. What are the classifications of hypertension?
- Primary Hypertension
- Secondary Hypertension
- Hypertensive Crisis
46
46. What is hypertensive crisis?
A dangerously high blood pressure requiring immediate intervention.
47
47. What are the instruments used in vital signs monitoring?
- Thermometer (for temperature)
- Stethoscope (for auscultation)
- Sphygmomanometer (for blood pressure)
- Pulse Oximeter (for oxygen saturation)
48
48. What is a pulse oximeter?
A device used to measure oxygen saturation levels in the blood.
49
49 . What are the classifications of blood pressure interpretation?
- Normal
- Elevated
- Hypertension Stage 1
- Hypertension Stage 2
- Hypertensive Crisis
50
50. What is the blood pressure range for Normal BP?
Systolic: Less than 120 mmHg
Diastolic: Less than 80 mmHg
51
51. What is the blood pressure range for Elevated BP?
Systolic: 120 – 129 mmHg
Diastolic: Less than 80 mmHg
52
52. What is the blood pressure range for Hypertension Stage 1?
Systolic: 130 – 139 mmHg
Diastolic: 80 – 89 mmHg
53
53. What is the blood pressure range for Hypertension Stage 2?
Systolic: 140 mmHg or higher
Diastolic: 90 mmHg or higher
54
54. What is the blood pressure range for Hypertensive Crisis?
Systolic: Higher than 180 mmHg
Diastolic: Higher than 120 mmHg
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What are the normal oxygen saturation (SpO2) levels?
95% - 100%
56
1. What are the classifications of hypothermia?
- Mild Hypothermia
- Moderate Hypothermia
- Severe Hypothermia
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2. What is the temperature range for Mild Hypothermia?
32 – 35°C (89.6 – 95.0°F)
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3. What are the signs and symptoms of Mild Hypothermia?
- Shivering
- Cold sensation
- Increased heart rate (tachycardia)
- Rapid breathing (tachypnea)
- Slight confusion
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4. What is the temperature range for Moderate Hypothermia?
28 – 32°C (82.4 – 89.6°F)
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5. What are the signs and symptoms of Moderate Hypothermia?
- Decreased shivering
- Slowed heart rate (bradycardia)
- Decreased level of consciousness
- Impaired coordination
- Confusion or drowsiness
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6. What is the temperature range for Severe Hypothermia?
Below 28°C (Below 82.4°F)
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7. What are the signs and symptoms of Severe Hypothermia?
- Loss of shivering
- Weak or absent pulse
- Severe confusion or unconsciousness
- Dilated pupils
- Irregular breathing or respiratory arrest
- Risk of cardiac arrest
63
1. A nurse is about to assess a patient’s vital signs. When should vital signs be taken?
a) At the time of admission
b) When there is a change in the patient’s health status
c) Before and after administering cardiovascular medications
d) All of the above
d) All of the above
64
2. A nurse is obtaining a temperature reading using a rectal thermometer. Which range represents a normal rectal temperature in Celsius?
a) 35.8 – 37.0°C
b) 36.5 – 37.5°C
c) 37.0 – 38.1°C
d) 36.8 – 37.9°C
c) 37.0 – 38.1°C
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3. A patient has an oral temperature of 38.5°C. What term describes this condition?
a) Hypothermia
b) Pyrexia
c) Bradypnea
d) Orthopnea
b) Pyrexia
66
4. A nurse is assessing an elderly patient’s temperature. Which method is most accurate?
a) Axillary
b) Rectal
c) Oral
d) Temporal
b) Rectal
67
5. A nurse is evaluating a patient who has been experiencing fever for three days. The patient’s temperature fluctuates between normal and elevated throughout the day. Which type of fever is this?
a) Remittent Fever
b) Relapsing Fever
c) Continuous Fever
d) Intermittent Fever
d) Intermittent Fever
68
6. A nurse is monitoring a patient with severe hypothermia. Which of the following clinical signs should the nurse expect?
a) Shivering and chills
b) Rapid breathing and warm skin
c) Frostbite and decreased heart rate
d) Increased blood pressure and sweating
c) Frostbite and decreased heart rate
69
7. A patient is shivering and experiencing gooseflesh due to the onset of a fever. What phase of fever is this?
a) Course (Plateau Phase)
b) Defervescence (Fever Abatement Phase)
c) Onset (Cold or Chill Phase)
d) Crisis Phase
c) Onset (Cold or Chill Phase)
70
8. A nurse is assessing an infant’s apical pulse. Where should the nurse place the stethoscope?
a) 2nd intercostal space, right sternal border
b) 4th intercostal space, lateral to the midclavicular line
c) 5th intercostal space, midclavicular line
d) Below the sternum at the xiphoid process
b) 4th intercostal space, lateral to the midclavicular line
71
9. A patient is experiencing tachycardia. What is their pulse rate likely to be?
a) Below 60 bpm
b) Between 60-100 bpm
c) Above 100 bpm
d) Irregular with no measurable rate
c) Above 100 bpm
72
10. A nurse is checking a patient’s pulse and notes an irregular rhythm. What should the nurse do next?
a) Count the pulse for 15 seconds and multiply by four
b) Ignore the finding since it is normal
c) Assess the apical pulse for one full minute
d) Document it as a normal finding
c) Assess the apical pulse for one full minute
73
11. A patient has a weak, thready pulse that disappears with slight pressure. How should this be documented?
a) 0 (Absent)
b) 1+ (Thready)
c) 2+ (Weak)
d) 3+ (Normal)
b) 1+ (Thready)
74
12. A nurse notes that a patient’s pulse is irregular and varies in strength between beats. What is this type of pulse called?
a) Normal Pulse
b) Bigeminal Pulse
c) Bounding Pulse
d) Intermittent Pulse
d) Intermittent Pulse
75
13. A nurse is assessing a patient’s respiratory rate. What should the nurse count?
a) The number of inhalations in one minute
b) The number of exhalations in one minute
c) One full inhalation and exhalation as one breath
d) The number of breaths per five minutes
c) One full inhalation and exhalation as one breath
76
14. A patient is breathing at a rate of 30 breaths per minute. What is this condition called?
a) Eupnea
b) Tachypnea
c) Bradypnea
d) Apnea
b) Tachypnea
77
15. A patient’s breathing is characterized by cycles of deep, rapid breathing followed by periods of apnea. What is this breathing pattern called?
a) Biot’s Respiration
b) Kussmaul’s Respiration
c) Cheyne-Stokes Breathing
d) Eupnea
c) Cheyne-Stokes Breathing
78
16. A nurse is assessing a patient’s blood pressure and notes a reading of 135/85 mmHg. How should this be classified?
a) Normal
b) Elevated
c) Hypertension Stage 1
d) Hypertension Stage 2
c) Hypertension Stage 1
79
17. A nurse is measuring a patient’s blood pressure and finds that the cuff is too small for the patient’s arm. What effect will this have on the reading?
a) It will be falsely low
b) It will be falsely high
c) It will be more accurate
d) It will not affect the reading
b) It will be falsely high
80
18. A patient is experiencing a sudden drop in blood pressure when standing up. What condition is this called?
a) Primary Hypertension
b) Orthostatic Hypotension
c) Secondary Hypertension
d) Hypertensive Crisis
b) Orthostatic Hypotension
81
19. A nurse is preparing to assess a patient’s blood pressure. What factors can cause an inaccurate reading?
a) The patient is talking during the measurement
b) The cuff is wrapped too loosely
c) The arm is positioned above heart level
d) All of the above
d) All of the above
82
20. A patient with hypertension is prescribed lifestyle modifications. Which intervention is appropriate?
a) Increasing sodium intake
b) Engaging in regular physical activity
c) Avoiding all forms of medication
d) Drinking more caffeinated beverages
b) Engaging in regular physical activity
83
1. A 75-year-old patient is brought to the ER after being found outside in cold weather. The nurse notes that the patient is confused, shivering, and has a core temperature of 34°C. What should the nurse do first?
a) Administer warm IV fluids
b) Apply heated blankets
c) Monitor for arrhythmias
d) Encourage oral warm fluids
b) Apply heated blankets
84
2. A nurse assesses a patient's blood pressure using a cuff that is too small. How will this affect the reading?
a) It will be falsely low
b) It will be falsely high
c) It will be more accurate
d) It will remain unchanged
b) It will be falsely high
85
3. A patient with severe pneumonia has an oxygen saturation of 88%. The nurse should anticipate which symptom?
a) Decreased respiratory rate
b) Cyanosis
c) Hypertension
d) Bounding pulse
b) Cyanosis
86
4. A patient has a temperature of 39.2°C, and the nurse observes chills and shivering. Which phase of fever is the patient in?
a) Onset (Cold/Chill Phase)
b) Plateau Phase
c) Defervescence
d) Crisis Phase
a) Onset (Cold/Chill Phase)
87
5. The nurse is assessing an elderly patient’s pulse and notes a heart rate of 48 bpm. What should the nurse check next?
a) Blood pressure
b) Oxygen saturation
c) Level of consciousness
d) Apical pulse for one full minute
d) Apical pulse for one full minute
88
6. A patient is experiencing a hypertensive crisis with a blood pressure of 200/130 mmHg. What is the nurse’s priority action?
a) Reassess the blood pressure in 30 minutes
b) Keep the patient supine and calm
c) Administer antihypertensive medication as ordered
d) Encourage oral fluids to reduce blood pressure
c) Administer antihypertensive medication as ordered
89
7. A patient’s blood pressure suddenly drops from 140/90 mmHg to 90/60 mmHg after standing up. What condition is suspected?
a) Primary Hypertension
b) Orthostatic Hypotension
c) Hypertensive Crisis
d) Normal Aging Process
b) Orthostatic Hypotension
90
8. A nurse is caring for a patient with hypothermia. The patient stops shivering, and their heart rate is slowing down. What does this indicate?
a) The patient is improving
b) The patient is entering moderate to severe hypothermia
c) The patient needs to be left to warm up naturally
d) The patient is in metabolic acidosis
b) The patient is entering moderate to severe hypothermia
91
9. A patient with a suspected stroke has a blood pressure of 220/120 mmHg. What should the nurse anticipate?
a) Administering IV antihypertensives
b) Encouraging the patient to ambulate
c) Increasing oral fluid intake
d) Checking blood pressure again in 4 hours
a) Administering IV antihypertensives
92
10. A nurse takes a patient’s blood pressure and notes a difference of 20 mmHg between the left and right arm. What should the nurse do next?
a) Report the finding to the physician
b) Reassess in 5 minutes
c) Document as a normal variation
d) Ignore and check another vital sign
a) Report the finding to the physician
93
11. A patient is being monitored for hypoxia. Which of the following findings is most concerning?
a) Oxygen saturation of 92%
b) Restlessness and confusion
c) Respiratory rate of 18 breaths per minute
d) Pale skin color
b) Restlessness and confusion
94
12. A nurse is assessing a patient's temperature. The patient has just consumed hot tea. What should the nurse do?
a) Proceed with an oral temperature reading
b) Wait 15-30 minutes before checking oral temperature
c) Take a rectal temperature instead
d) Document the temperature as inaccurate
b) Wait 15-30 minutes before checking oral temperature
95
13. A patient with a history of COPD has a respiratory rate of 28 breaths per minute and is using accessory muscles to breathe. What should the nurse do first?
a) Increase oxygen flow to 6 L/min
b) Place the patient in High Fowler’s position
c) Instruct the patient to take deep breaths
d) Administer a sedative to reduce anxiety
b) Place the patient in High Fowler’s position
96
14. A nurse is assessing a patient's radial pulse and notes an irregular rhythm. What is the most appropriate action?
a) Notify the physician immediately
b) Check the pulse oximeter reading
c) Assess the apical pulse for one full minute
d) Reassess the radial pulse after 10 minutes
c) Assess the apical pulse for one full minute
97
15. A nurse notices a patient’s blood pressure drops by 30 mmHg when moving from lying to standing. What should the nurse do?
a) Encourage slow position changes
b) Administer IV fluids
c) Have the patient walk to improve circulation
d) Elevate the legs
a) Encourage slow position changes
98
1. What are the types of hypertension?
- Primary Hypertension
- Secondary Hypertension
99
2. What is Primary Hypertension?
High blood pressure with no identifiable cause; also called essential hypertension.
100
3. What is Secondary Hypertension?
High blood pressure caused by an underlying condition such as kidney disease, endocrine disorders, or medications.
101
4. What are the risk factors for hypertension?
- Modifiable Risk Factors
- Non-Modifiable Risk Factors
102
5. What are the modifiable risk factors for hypertension?
- Unhealthy diet (high sodium, low potassium)
- Lack of physical activity
- Obesity
- Smoking
- Excessive alcohol intake
- Stress
- Poor sleep habits
103
6. What are the non-modifiable risk factors for hypertension?
- Age (higher risk as people get older)
- Family history of hypertension
- Genetics
- Ethnicity (higher prevalence in certain populations)
- Gender (men have a higher risk at younger ages; postmenopausal women have increased risk)
