Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

NURS1543 > WEEK 2- VITAL SIGNS > Flashcards

WEEK 2- VITAL SIGNS Flashcards

(82 cards)

Start Studying
1
Q

Outline components included in the general survey.

A

Physical appearance
body structure
mobility
behavior

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Outline equipment required to complete a general survey

A

physical appearance:
- age
- sex
- LOC
- skin colour
- facial features

body structure
- stature
- nutrition
- symmetry
- posture
- position
- contour

mobility
- gait
- range of motion

behavior
- facial expression
- mood and affect
- speech
- dress
- personal hygiene

measurement
- weight, height, BMI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Identify measurement components related to height, weight, Body Mass Index (BMI), & waist-to-hip ratio.

A

Weight in kg
Height in cm
BMI
Normal 18.5 to 24.9

***Note: Ensure the BMI formula includes the denominators being squared (Jarvis p. 156)

Weight in Kg
Height in metres²

Waist-to-hip ratio = waist circumference
Hip circumference

Waist circumference > 88 cm in women and > 102 places individuals at risk for diabetes, heart disease and hypertension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Distinguish approaches & techniques of general survey when examining clients across the lifespan.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Outline relationship between health promotion & objective data gathered during general survey.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Describe assessment findings in the following growth & development abnormalities of hypopituitary Dwarfism,

A

insufficient growth hormone in pituitary gland

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

gigantism

A

too much growth hormone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

acromegaly (hyperpituitarism),

A

too much growth hormone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

a-chondro-plastic Dwarfism,

A

abnormal bone growth in face, hands, etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

anorexia nervosa

A

BMI below 18, fear of gaining weight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Endogenous obesity: Cushing’s Syndrome.

A

chronic exposure to excessive levels of cortisol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Outline equipment required to complete a vital signs assessment

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Identify strategies to maintain infection prevention & control safety principles.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Overview different methods of obtaining a temperature.

A
  • rectal (most invasive, infants)
  • oral (least invasive, common)
  • axillary
  • tympanic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Outline range of normal temperatures via different routes

A

oral- 35.8-37.3
rectal- 36-37/38

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Differentiate between expected findings and abnormal findings (hyperthermia & hypothermia) and identify potential physiologic causes

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Outline developmental differences related to technique & findings.

A

Range of Afebrile – 35.8-37.4C
Febrile 37.5 C and >

Pediatric population
Canadian Paediatric Society (2011) recommendations for rectal temperatures
Older Population
With age less likely to be febrile, but great risk for hypothermia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Document findings in narrative and graphic form.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Outline methods of obtaining a peripheral pulse.

A

Radial pulse
Pads of your 3 fingers
Place on flexor of wrist along the radius bone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Identify findings of rate, rhythm, force & expected findings when assessing a peripheral pulse.

A

Rate
Normal, bradycardia & tachycardia
Rhythm
Sinus arrhythmia
Force (0- 3+)
0- absent pulse
1+ weak
2+ normal
3+ bounding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Differentiate between expected findings and abnormal findings (bradycardia & tachycardia) and identify potential physiologic causes.

A

normal findings
50-95

bradycardia- less than 50
tachycardia- more than 100

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Outline developmental differences related to technique & findings.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Outline method of assessing respirations.

A

maintain position for counting pulse
- assess, rate, rhythm, quality (relaxed, quiet, automatic)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Identify findings of rate & rhythm & expected findings.

A

infants (30-40)
2yr old (25-32)
adults (10-20)
less respirations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Differentiate between expected findings and abnormal findings (bradypnea & tachypnea ) and identify potential physiologic causes.
bradypnea- slow respirations (less) less than 10. tachypnea- fast respirations (more) more than 20 in a adult.
26
Outline developmental differences related to technique & findings.
27
Outline method of obtaining a blood pressure using the one step & two step methods.
Wait 5 minutes Heart level Palpate brachial artery Medial to biceps tendon Above antecubital fossa Wrap cuff 1 inch above brachial artery Ausculatory Gap *abnormal finding Palpate brachial artery Inflate cuff until pulsation is obliterated And then, 20-30mm Hg above Deflate cuff quickly Wait 15-30 seconds Begin BP
28
Identify findings of Korotkoff’s sounds.
Inflate cuff to maximum inflation level Deflate slowly 2 mm Hg per heartbeat Note Korotkoff sounds I & V
29
Differentiate between expected findings & abnormal findings (hypotension & hypertension) & identify potential physiologic causes.
Hypertension Contextual 140/90 Hypotension <95/60
30
Outline common technique errors that lead to false results.
- cuff too narrow or to big (can yield falsely high or low results)
31
Outline technique & potential findings of orthostatic hypotension.
Specific change in pulse and BP observed through a series of position changes Supine, sitting with feet dangling, and standing 2 minutes in between so that venous congestion subsides Orthostatic hypotension is a drop in systolic BP of more than 20mmHg or increase of pulse of more than 20 bpm Reason for taking: hypertension, volume depletion, or reports of syncope Prolonged bedrest, older age
32
Outline developmental differences related to technique & findings.
33
Outline method of obtaining an oxygen saturation.
Pulse Oximetry is measured with a pulse oximeter This will provide both a pulse and an oxygen saturation reading What reading is expected for within normal range for Oxygen Saturation?
34
Identify expected findings and abnormal findings
95 or more is expected abnormal would be less than 95.
35
Outline developmental differences related to technique.
36
Outline the use of electronic vital signs monitoring system.
37
Review physiologic process of the pain sensation. Including sources & types of pain.
Nociceptive; Caused by tissue injury; well localized Described as “aching” or “throbbing” Somatic Superficial from skin and subcutaneous tissue (cutaneous pain) Deep from joints, tendons, muscles, or bone Visceral From direct injury or stretching of large interior organs Result of tumour, ischemia, distension, or contraction Neuropathtic Caused by lesion or disease affecting somatosensory nervous system Results from damage to nerve pathway Caused by direct nerve trauma, infections, metabolic problems; may be drug induced Described as “burning” or “shooting” Manifestations vary among patients Referred Originates in one location but is felt in another site Innervated by same spinal nerve
38
Discuss developmental & social determinants of health considerations that relate to pain.
39
Describe the factors of a complete pain assessment.
40
Describe the use of standardized tools for assessing pain.
face pain chart (non verbal pain expressions)
41
Outline the components of objective pain assessment.
42
Outline developmental differences related to techniques, tools, & findings.
Neonates Dependent on behaviour and physiological cues More than one assessment approach There is no increase in pain as one ages Pain is always associated with pathology and not aging
43
Identify reasons for validating assessment findings of pain with the client.
44
vital signs
Temperature Pulse Respiratory Rate Blood pressure Pain Assessment
45
pulse
With every heart beat: Stroke volume (SV) approximately 70ml Pressure wave is generated results in a peripheral pulse beats per minute (bpm)
46
8 factors affecting BP
age, gender, ethnocultural background, diurnal rhythm, weight, exercise, stress/emotions.
47
Blood pressure
Force of blood pushing against side of vessel wall Changes with cardiac cycle Two cycles Systole Diastole
48
systole
Systole left ventricle contraction pushes blood out into arterial blood stream Systolic - maximum force on artery wall Systolic ~ 120mm Hg
49
Levels of BP (5)
Cardiac Output (CO) –volume pumped per minute CO = SV x R Peripheral Vascular Resistance (PVR) Opposition to blood flow Viscosity Volume of Circulating Blood Elasticity of Vessel Walls
50
equipment- BP
Stethoscope and aneroid sphygmomanometer Width of BP cuff should equal 40% of the circumference of patient’s arm A cuff that is too narrow yields a falsely high BP
51
subjective data- pain
Pain is whatever the experiencing person says it is, existing whenever he/she says it does” (McCaffery, 1968) We have pain assessment questions we can ask And assessment tools
52
OPQRSTU
Initial pain assessment (PQRSTU) Onset : when did the pain start Provocative or palliative: Relieved with rest? Previous treatments effective? Quality of pain: Words to describe pain? Region of body: Where? Radiates? Severity: How patient would rate on intensity scale? Timing and onset of pain: When started? Constant, dull, or intermittent? Changed over time? Pain-free periods? Understanding of pain: What patient believes is causing the pain? Goal for comfort? Medications used?
53
2 TYPES OF PAIN
ACUTE AND CHORNIC
54
The young and the old are the most sensitive to environmental temperature fluctuations. True or False
TRUE
55
For an accurate oral temperature the thermometer should be left in place for 10 minutes . True or False
FALSE
56
Normally the apical pulse is greater than the radial pulse. True or False
FALSE
57
Arterial pressure is a result of the interaction between pumping action of the heart, peripheral vascular resistance, blood volume and viscosity. True or False
TRUE
58
Nursing goals and interventions for the client who is febrile are designed to determine the etiology of the fever. True or False
FALSE
59
Identify the 8 factors that significantly affect blood pressure:
Age. Blood pressure tends to increase with age. ... Family history and genetics. High blood pressure often runs in families. ... Lifestyle habits. ... Medicines. ... Other medical conditions. ... Race or ethnicity. ... Sex. ... Social and economic factors.
60
Pulse rate is affected by
amount of time since the last meal degree of involvement in health care developmental level stress
61
Which of the following temperature readings is considered to be most accurate?
RECTAL
62
Your client’s vital signs are BP=80/50, T= 38.9C, P=112, RR=26. Your client is:
Hypotensive, tachycardic, tachypneic, and febrile
63
Your client’s vital signs are BP= 130/78, T=36.9C, P=84, RR=16. Your client is :
within normal range for all vital signs
64
The systolic pressure is ausculatated at 140 mm Hg, the point of muffling is heard at 80mm Hg and the last sound that you auscultate is at 70 mm Hg. Document the appropriate Blood pressure measurement of? ___140/70________
140/70
65
The normal respiration for an adult is _____10______to ______20_______
10/20
66
Bradycardia___pulse below 60__
BELOW 60
67
Orthostatic Hypotension- 
fall in systolic blood pressure greater than 20 millimeters of mercury (mmHg) or a fall of in diastolic pressure greater than 10 mmHg
68
Systolic pressure
– pressure in the heart when the heart is at work
69
Pulse pressure
the difference between the systolic and diastolic pressure
70
Symptoms, such as pain, are often influenced by a person’s cultural heritage. Which of the following is a true statement in regard to pain?
The ethnic background of a patient is important in a nurse’s assessment of that patient’s pain.
71
Which of the following statements is true regarding pain?
Just as patients vary in their perception of pain, so will they vary in their expression of it.
72
A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. You would:
consider this a normal finding for a 1-month-old infant.
73
Which of the following statements is true regarding vital sign measurements in aging adults?
An increased respiratory rate and a shallower inspiratory phase are expected findings.
74
Which of the following is an example of acute pain?
Kidney stones
75
Which question would best assess the quality of the patient’s pain
What does your pain feel like?
76
Pain signals are carried to the central nervous system by way of:
afferent sensory fibers
77
Deep somatic pain originates from sources in which of the following locations?
Bone and joints
78
Which of the following has been found to influence pain sensitivity in women
Hormonal changes
79
Which of the following types is short, self-limiting pain that dissipates after injury?
acute
80
normal temp
37.2
81
temp is affected by
hormonal changes diurnal cycle mensuration cycle exercise older adults - 36.2
82
yes

NURS1543 (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions