CH29 Vital Signs (Test 2)

Factors that affect body temperature (6)

1. Age 2. Circadian rhythms 3. Exercise 4. hormones 5. stress 6. environmental

Factors affect the body's heat production (5)

1. Basal Metabolic rate 2. Muscle activity 3. Throxine output 4. Epinephrine 5. Fever

Circulatory factors that influence blood pressure (BP) are:

1. Cardiac Outcome. The amount of blood ejected from the heart. 2. Blood Volume. The amount of blood circulating throughout the body. The normal adult blood volume is 5 liters. A drop in blood volume causes blood pressure to decrease and the pulse to increase. 3. Peripheral Vascular Resistance. The resistance the blood encounters as it flows through the vessels. 4. Blood viscosity. The ratio between blood cells and blood plasma. 5. Vessel compliance. The elasticity of the smooth muscles of the vessels.

Factors essential to normal functioning of the respiratory system. (2)

1. Integrity of the airway system to transport air to and from the ungs 2. Properly functioning alveolar system in lungs

What is an average body temperature?

96.8F - 99.5F 36.0C - 37.5C

What does a pulse oximeter read?

A pulse oximeter measures the percent of hemoglobin saturated with oxygen. A normal result is 95% to 100%

Mr. Nyambi, your African American client, requests information from you regarding the best ways to lower his blood pressure. Which of the following statements about modifiable risk factors would be most important for you to include in client teaching? A. "It is important to routinely exercise." B. "Your ethnicity increases your risk for high blood pressure." C. "Your blood pressure will likely rise as you age." D. "The healthcare provider will likely order medication first to lower your blood pressure."

A. "It is important to routinely exercise."

The nurse is preparing to assess the client's temperature. Which statements by the nurse indicate the nurse's understanding of temperature assessment? Select all that apply. A. "Not all clients are candidates for assessing temperature via the oral method." B. "The axillary method of measuring temperature is the most accurate method." C. "The tympanic temperature is taken with an electronic thermometer using an infrared probe." D. "The temporal artery thermometer is quick and scans over the temporal artery on the forehead." E. "A rectal temperature may be obtained if the client is comatose, confused, having seizures, or is unable to close his or her mouth."

A. "Not all clients are candidates for assessing temperature via the oral method." C. "The tympanic temperature is taken with an electronic thermometer using an infrared probe." D. "The temporal artery thermometer is quick and scans over the temporal artery on the forehead." E. "A rectal temperature may be obtained if the client is comatose, confused, having seizures, or is unable to close his or her mouth."

It would be appropriate to delegate the taking of vital signs of which client to unlicensed personnel? A. A client being prepared for elective facial surgery with a history of stable hypertension B. A client receiving a blood transfusion with a history of transfusion reactions C. A client recently started on a new antiarrhythmic agent D. A client who is admitted frequently with asthma attacks

A. A client being prepared for elective facial surgery with a history of stable hypertension

An adult has bandages over bilateral wrists. For routine pulse assessment, which site is best for arterial pulse evaluation? A. Carotid arteries B. Dorsalis pedis arteries C. Femoral arteries D. Brachial arteries

A. Carotid arteries

Which of the following factors might cause a client's blood pressure to increase? Select all that apply. A. Decreased elasticity of the smooth muscles of the vessels B. Decreased blood viscosity C. Increased cardiac output D. Increased blood volume E. Decreased peripheral vascular resistance

A. Decreased elasticity of the smooth muscles of the vessels C. Increased cardiac output D. Increased blood volume Decreased elasticity of the smooth muscles of the vessel walls results in decreased compliance of those vessels to dilate in response to increased blood volume, thus increasing blood pressure. Increased blood volume and increased cardiac output raise blood pressure. Decreased blood viscosity and decreased peripheral vascular resistance result in lower blood pressure, as it is easier for blood to flow through the vessels, resulting in less effort exerted by the heart.

Which statement(s) describe the process of respiration? Select all that apply. A. Exchange of oxygen and carbon dioxide B. Oxygen diffuses into a capillary C. Movement of lungs D. Oxygen is obtained from the air and transported to alveoli E. Chest wall rises and falls

A. Exchange of oxygen and carbon dioxide B. Oxygen diffuses into a capillary D. Oxygen is obtained from the air and transported to alveoli

Which of the following factors generally results in a decreased pulse rate when compared to normal values for the adult population? A. Healthy teenager B. Being an infant or child C. Acute blood loss D. Fever

A. Healthy teenager The expected pulse rate of a healthy teenager is 50-90 beats per minute, whereas an adult's is typically 60-100 beats per minute. An infant or child, client with a fever, or client with acute blood loss will generally have an increased pulse rate compared to the general adult population.

The body temperatures alternate at regular intervals between periods of fever and periods of normal temperatures. A. Intermittent fever B. Remittent fever C. Relapsing fever D. Constant fever

A. Intermittent fever

The nurse is preparing to assess the client's temperature. Which assessment finding would the nurse recognize as an elevated temperature? A. Oral 37.7°C (99.9°F) B. Axillary 36.3°C (97.3°F) C. Tympanic 36.5°C (97.7°F) D. Temporal 37.5°C (99.5°F)

A. Oral 37.7°C (99.9°F)

The nurse is caring for a hypertensive client in the health clinic. Which circulatory factor could contribute to the client's elevated blood pressure? A. Peripheral vascular resistance B. Age C. Ethnicity D. Respiratory rate

A. Peripheral vascular resistance

When the skin becomes chilled over the entire body, which physiological processes to increase the body temperature takes place (select all that apply): A. Shivering increases heat production B. Sweating is inhibited to decrease heat loss C. Vasoconstriction decreases heat loss D. Shivering decreases heat production E. Vasodialation decreases heat loss

A. Shivering increases heat production B. Sweating is inhibited to decrease heat loss C. Vasoconstriction decreases heat loss

Which statement(s) are true about factors that affect core body temperature? Select all that apply. A. Strenuous exercise can increase core temperature by 2°-5°F. B. Lack of subcutaneous fat can increase sensitivity to temperature changes in the environment. C. Core body temperature does not generally vary throughout the day. D. Illness that impairs the function of the hypothalamus can cause hyperthermia. E. A decrease in epinephrine and norepinephrine during times of stress increases metabolic activity and temperature.

A. Strenuous exercise can increase core temperature by 2°-5°F. B. Lack of subcutaneous fat can increase sensitivity to temperature changes in the environment. D. Illness that impairs the function of the hypothalamus can cause hyperthermia.

A temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours. A. fever spike B. Heat exhaustion C. Heat stroke

A. fever spike

Factors That Influence Vital Signs: Blood Pressure

Age. Blood pressure rate increasingly rises through age 18 and then tends to stabilize. Elderly clients will have raised blood pressure due to a decrease in the elasticity of the arteries. Gender. After puberty, females demonstrate a lower blood pressure than males. Ethnicity. In the United States, Caucasian clients will usually have a lower blood pressure compared to African American clients.2 Obesity. Obesity is a risk factor for hypertension. Physical activity. Physical activity increases cardiac output, which increases blood pressure. Stress. Stress increases cardiac output and arterial vasoconstriction, thus increasing blood pressure. Diurnal variations. Blood pressure is usually low in the early morning and then steadily increases, reaching its peak in the late afternoon or early evening. Medications. Many medications increase or decrease blood pressure.

Factors That Influence Vital Signs: Pulse

Age. The pulse rate of an infant or child is higher than that of an adolescent or adult. By the middle teen years (age 16) the pulse rate averages approximately 70 beats per minute. Gender. The average pulse rate for adult females is higher than that for males. Exercise. The pulse rate increases with exercise. Stress. The pulse rate increases in response to stress, anxiety, or fear. Fever. The pulse rate increases in response to peripheral vasodilatation during a fever. Hemorrhage. The pulse rate increases in response to blood loss. Medication. Some medications either increase or decrease the pulse rate.

You educate your client, Mr. Nyambi, that blood pressure, peripheral vascular resistance, and blood flow all affect arterial circulation. Mr. Nyambi states, "I do not understand the difference between systolic and diastolic pressure." You should include which statement in the education of the client? A. "Systolic pressure occurs when the right atrium contracts." B. "Diastolic pressure occurs when the heart is at rest." C. "Diastolic pressure occurs during the heart's contraction period." D. "Systolic pressure happens when the heart relaxes."

B. "Diastolic pressure occurs when the heart is at rest."

The nurse is preparing to assess the client's temperature. Which statement by the nurse about temperature regulation requires further teaching from the charge nurse? A. "Infants are highly susceptible to changes in environmental temperature." B. "Environmental changes in temperature are unlikely to affect the elderly client." C. "An illness like infection can cause the client's temperature to increase." D. "If the client is under a lot of stress their temperature can increase."

B. "Environmental changes in temperature are unlikely to affect the elderly client."

The nurse is caring for a 45-year-old client who is in the clinic for an annual checkup. The client's blood pressure reading is 139/82 mmHg. Which statement by the nurse indicates the nurse's correct understanding of this client's blood pressure? A. "The client's blood pressure is within the normal range for an adult." B. "This client is experiencing pre-hypertension and will need close monitoring." C. "The client is hypertensive and will be placed on blood pressure medications." D. "This client's blood pressure reading is low."

B. "This client is experiencing pre-hypertension and will need close monitoring."

When measuring the amplitude of a client's pulse, what is the scale indication for a weak or barely palpable pulse? A. 0+ B. 1+ C. 3+ D. 2+

B. 1+

For a client with a previous blood pressure of 138/74 and pulse of 64, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading? A. 10-20 seconds B. 30-45 seconds C. 1-1.5 minutes D. 3-3.5 minutes

B. 30-45 seconds

You are educating a client about how to monitor his blood pressure at home. You describe the sounds that the client will hear as he takes his blood pressure. How many sounds will be heard throughout this process? A. 3 B. 5 C. 6 D. 4

B. 5

What is the expected oral temperature range of a healthy adult? A. 98.7°F-100.5°F B. 97.7°F-99.5°F C. 95.7°F-97.7°F D. 96.7°F-98.5°F

B. 97.7°F-99.5°F

The nurse is assessing the vital signs of a client. How would the nurse assess the client's radial pulse? A. By placing a finger along the posterior wrist along the radius bone B. By placing two to three fingers on the anterior wrist along the radius bone C. By counting the pulse for 30 seconds if the pulse is irregular D. By providing firm pressure over the radial pulse

B. By placing two to three fingers on the anterior wrist along the radius bone

The client's temperature at 0800 using an oral electronic thermometer is 36.1C (97.2F). If the respiration, pulse, and blood pressure were within normal range, what would the nurse do next? A. Wait 15 minutes and retake B. Check what the client's temperature was the last time it was taken C. Retake using a different thermometer D. Chart the temperature; it is normal

B. Check what the client's temperature was the last time it was taken

Result of excessive heat and dehydration with a temperature of 101-102F A. fever spike B. Heat exhaustion C. Heat stroke

B. Heat exhaustion

Signs: paleness, dizziness, nausea, vomiting, fainting A. fever spike B. Heat exhaustion C. Heat stroke

B. Heat exhaustion

Wide range of temperature fluctuations. A. Intermittent fever B. Remittent fever C. Relapsing fever D. Constant fever

B. Remittent fever

Which of the following are correct statements about methods used to assess core temperature? Select all that apply. A. The axillary temperature method is least invasive and most accurate. B. The use of a rectal thermometer in a client who is actively having seizures is contraindicated. C. The oral method is most accurate when glass thermometers are utilized. D. The tympanic route assesses temperature via the ear canal. E. A temporal thermometer scans across the temporal artery in the neck.

B. The use of a rectal thermometer in a client who is actively having seizures is contraindicated. D. The tympanic route assesses temperature via the ear canal. E. A temporal thermometer scans across the temporal artery in the neck.

the measurement of force exerted against the walls of arterial blood vessels.

Blood pressure

The charge nurse is teaching a new nurse about the body's regulation of respirations and respiratory assessment. Which statement by the new nurse indicates a need for further teaching by the charge nurse? A. "In order for the body to have adequate oxygenation the body needs a healthy and intact respiratory system." B. "The chest wall effortlessly rises and falls with each breath." C. "Respiratory rate is the continuous exchange of oxygen and carbon dioxide in the lungs." D. "To accurately assess the respiratory rate I should not tell the client I am assessing their respiratory rate."

C. "Respiratory rate is the continuous exchange of oxygen and carbon dioxide in the lungs."

Which client meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse? A. A client who is in shock B. The pulse changes with body position changes C. A client with an arrhythmia D. It is less than 24 hours since a client's surgical operation

C. A client with an arrhythmia

AN 85 year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are appropriate for taking the temperature? Select all that apply A. Oral B. Rectal C. Axillary D. Tympanic E. Temporal artery

C. Axillary D. Tympanic E. Temporal artery

A temperature of 106F or higher. A. fever spike B. Heat exhaustion C. Heat stroke

C. Heat stroke

Have warm, flushed skin, and often do not sweat. A. fever spike B. Heat exhaustion C. Heat stroke

C. Heat stroke

May be delirious, unconscious, or having seizures. A. fever spike B. Heat exhaustion C. Heat stroke

C. Heat stroke

Short febrile periods of a few days are interspersed with periods of 1 to 2 days of normal temperature. A. Intermittent fever B. Remittent fever C. Relapsing fever D. Constant fever

C. Relapsing fever

The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following? A. Shallow respirations B. Wheezing C. Shortness of breath D. coughing up blood

C. Shortness of breath

After you welcome and help Mrs. Nelson settle into her new room on your unit, she enjoys visiting with friends then takes an hour-long nap. Upon awakening with a startled feeling, unsure where she is, you take her vital signs and discover a blood pressure mmHg of 146/94. When documenting this information, which describes your nursing assessment? A. "Client has signs of hypotension. Will educate client to increase fluid intake and recheck in one hour." B. "Client has symptoms of orthostatic hypotension; educated to call for assistance with ambulating." C. "Client's blood pressure within expected limits. Will reevaluate in 4 hours." D. "Client is currently hypertensive. Will reassess blood pressure in 15 minutes."

D. "Client is currently hypertensive. Will reassess blood pressure in 15 minutes."

A nursing diagnosis of ineffective peripheral tissue perfusion would be validated by which one of the following? A. Bounding radial pulse B. Irregular apical pulse C. Carotid pulse stronger on the left side than the right D. Absent posterior tibial and pedal pulses

D. Absent posterior tibial and pedal pulses

The body temperature fluctuates minimally but always remains above normal. A. Intermittent fever B. Remittent fever C. Relapsing fever D. Constant fever

D. Constant fever

The nurse is assessing a 65-year-old client who complains of being short of breath when lying flat. The nurse places the client in high Fowler position and the client's breathing improves. Which unexpected finding is the client experiencing? A. Kussmaul breathing B. Apnea C. Hyperventilation D. Orthopnea

D. Orthopnea

Mrs. Jones is recovering from a serious viral pneumonia that resulted in sepsis/shock and required endotracheal intubation with mechanical ventilatory support. Mrs. Jones is now greatly improved, and all of the invasive arterial lines have been discontinued and she has been transferred to your care on the medical respiratory step-down unit. Which is the best method for routinely assessing Mrs. Jones' oxygen saturation at this point in time? A. Count number of respirations for one full minute B. Arterial blood gas C. Assess for circumoral cyanosis D. Pulse oximeter device

D. Pulse oximeter device

When the nurse enters the room to measure vital signs in preparing the client for a diagnostic test, the client is on the phone. What technique should the nurse use to determine the respiratory rate? A. Count the respirations during conversational pauses. B. Ask the client to end the phone call now and resume it at a later time C. Wait at the client's bedside until the phone call is completed and then count respirations D. Since there is no evidence of distress or urgency, defer the measurement.

D. Since there is no evidence of distress or urgency, defer the measurement.

Where can a pulse oximeter be place on a client?

Earlobe, nose, finder, toe, forehead, or around the hand or foot of the neonate

Factors That Influence Vital Signs: Respiratory Rate

Exercise Stress Increased temperature Increased altitude Medications

A blood pressure cuff that is too wide or narrow will do what?

Give a false reading

the continuous exchange of oxygen and carbon dioxide in the lungs

Respirations

the measurement of breathing cycles (inspiration and expiration) taken in one minute.

Respiratory rate

Where should the artery be held while reading a blood pressure measurement?

The artery should be held at heart level

When auscultating the blood pressure, the nurse hears: from 200 mmHg to 180mmHg: silence; then: a thumping sound continuing down to 150 mmHg: muffled sounds continuing down to 130 mmHg: soft thumping sounds continuing down to 105 mmHg; muffled sounds continuing down to 95mmHg; then silence.

This blood pressure should be recorded as 180/105/90 using the systolic/ 1st diastolic/ 2nd diastolic convention

Which describes a remittent fever? a. A wide range of temperature fluctuations within a 24-hour period, all above normal ranges b. Short febrile periods of a few days mixed with periods of 1 or 2 days of normal temperatures c. Body temperature fluctuates at regular intervals from normal to above normal temperatures d. A rapid rise to a fever with return to normal body temperature in a short time

a. A wide range of temperature fluctuations within a 24-hour period, all above normal ranges

Balance between the heat produced and the heat lost from the body. a. Body temperature b. core temperature c. surface temperature d. heat balance e. basal metabolic rate

a. Body temperature

The nurse is caring for a 45-year-old male African American client who weighs 110 kg (242 lb). The nurse is preparing to assess the client's blood pressure. Which would the nurse recognize as factors that will affect this client's blood pressure? Select all that apply. a. Gender b. Ethnicity c. Hormones d. Weight e. Age

a. Gender b. Ethnicity d. Weight

The nurse is working in an primary care clinic. Which assessment finding of a client's pulse would the nurse recognize as an unexpected finding? Select all that apply. a. Pulse rate of 72 in a 1-year-old client b. Pulse rate of 88 in an 8-year-old client c. Pulse rate of 55 in a 10-year-old client d. Pulse rate of 53 in a 45-year-old client e. Pulse rate of 110 in an 88-year-old client

a. Pulse rate of 72 in a 1-year-old client d. Pulse rate of 53 in a 45-year-old client e. Pulse rate of 110 in an 88-year-old client

The nurse is preparing to assess the client's vital signs. Which principles would the nurse consider? Select all that apply. a. Respirations should be relaxed and regular. b. A pulse oximeter is a device used to measure the oxygen saturation of the blood. c. The client should be allowed to rest for 15 minutes before the blood pressure is taken. d. The client should be told that the nurse will count their respirations before the nurse begins. e. A Doppler can be used to assess a pulse that is not palpable.

a. Respirations should be relaxed and regular. b. A pulse oximeter is a device used to measure the oxygen saturation of the blood. e. A Doppler can be used to assess a pulse that is not palpable.

The nurse is preparing to assess the client's respiratory rate. Which assessment finding would be the cause of an increase in the client's respiratory rate? a. Temperature 39.2°C (102.5°F) b. Blood pressure 110/75 mmHg c. Age 32 d. Caucasian

a. Temperature 39.2°C (102.5°F)

The nurse is performing an initial assessment on a client. Which data would the nurse collect when assessing the client's pulse? Select all that apply. a. The pattern of beats and intervals between beats b. The force of each beat c. The elasticity of the arterial wall d. A swooshing sound e. The number of beats per minute

a. The pattern of beats and intervals between beats b. The force of each beat c. The elasticity of the arterial wall e. The number of beats per minute

he transfer of heat from the surface of one object to the surface of another without contact between the two objects. a. radiation b. conduction c. convection d. evaporation

a. radiation

Define the concept of thermoregulation?

ability to maintain normal body temperature.

A client that does not have a fever is referred to as

afebrile

Factors that affect a persons pulse rate:

age, sex, exercise, presence of fever, certain medications, hypovolemia, stress, position changes,and pathology

The nurse is evaluating a new nurse's ability to recognize the different types of fever in clients. Which statements by the new nurse indicates accurate knowledge? Select all that apply. a. "Intermittent fever occurs when the body goes through a wide range of body temperatures throughout a 24-hour period." b. "A relapsing fever is when the body has short febrile periods of a few days that are interspersed with periods of normal body temperature." c. "The body can have a constant fever when the temperature remains elevated." d. "A fever spike is when there is a rapid rise in body temperature with a return to normal temperature within a couple of hours." e. "Remittent fever is when the body temperature alternates between normal body temperature and elevated temperature."

b. "A relapsing fever is when the body has short febrile periods of a few days that are interspersed with periods of normal body temperature." c. "The body can have a constant fever when the temperature remains elevated." d. "A fever spike is when there is a rapid rise in body temperature with a return to normal temperature within a couple of hours."

The nurse is evaluating a new graduate's ability to assess a radial pulse. Which statement by the new nurse indicates the need for further teaching? a. "I will need to determine the rate and rhythm of the pulse." b. "When checking the pulse I will measure the elasticity using the scale 0, 1+, 2+, 3+, or 4+." c. "The pulse is the reflection of the amount of blood ejected with each heartbeat." d. "The number of pulsations felt per minute is called the heart rate."

b. "When checking the pulse I will measure the elasticity using the scale 0, 1+, 2+, 3+, or 4+."

The nurse is preparing to assess the client's oxygen saturation. Which findings should the nurse anticipate would impact the measurement of the client's oxygen saturation? a. Weight b. Low hemoglobin c. Increasing age d. Male gender

b. Low hemoglobin

The transfer of heat from one molecule to a molecule of lower temperature. a. radiation b. conduction c. convection d. evaporation

b. conduction

Temperature in the deep tissue of the body. a. Body temperature b. core temperature c. surface temperature d. heat balance e. basal metabolic rate

b. core temperature

The dispersion of heat by air currents. a. radiation b. conduction c. convection d. evaporation

c. convection

Temperature of the skin, subcutaneous tissue and fat. a. Body temperature b. core temperature c. surface temperature d. heat balance e. basal metabolic rate

c. surface temperature

Continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin. a. radiation b. conduction c. convection d. evaporation

d. evaporation

The amount of heat produced by the body equals the amount of heat lost. a. Body temperature b. core temperature c. surface temperature d. heat balance e. basal metabolic rate

d. heat balance

the pressure during the period when the heart is relaxed

diastolic pressure

The rate of energy utilization in the body required to maintain essential activities. a. Body temperature b. core temperature c. surface temperature d. heat balance e. basal metabolic rate

e. basal metabolic rate

Hypothermia involves three mechanisms

excessive heat loss, inadequate heat production by body cells, and increasing impairment of hypothalamic thermoregulation

A client who has a fever is referred to as

febrile

The number of pulsing sensations felt per minute is called the

heart rate

A very high fever above 41C (105.8F) is called

hyperpyrexia

Which gland is the center for thermoregulation?

hypothalmus

A temperature below 96.8F (36.0C) is considered

hypothermia

Four common types of fever:

intermittent, remittent, relapsing and constant

What occurs when the blood pressure falls as the client assumes an upright position

orthostatic hypotension

A fever between 100.4F (38C) is called

pyrexia

What do you call a body temperature above the usual range?

pyrexia, hyperthermia or fever

With each pulsation, it is necessary to determine

rate, rhythm, amplitude, and elasticity of the artery

the pressure of the blood when the left ventricle contracts.

systolic pressure

What are the four traditional vital signs?

temperature, pulse, respiration, and blood pressure