NURS 1005: Unit 2 -Ch. 19
Infant (0-1 yr) Normal Blood Pressure Ranges: _____ (mm Hg)
73/55
Normal Pulse Rate Ranges for School-aged (5-12 yrs) are _____ to _____ (Beats/Min)
75 to 110
Normal Pulse Rate Ranges for Toddler (1-3 yrs) are _____ to _____ (Beats/Min)
80 to 140
What is the pressure that is caused by the blood when the heart muscle contracts, sending a wave of blood through the artery
Systolic pressure
True or False. Waste products such as carbon dioxide are created as a result of normal cellular function, namely metabolism
T
A person who has an increased body temperature is said to have a _____
fever
Normal body temperature ranges from _____°F to _____°F above or below the range considered "normal"
0.5°F to 1°F
School-aged (5-12 yrs) Normal Blood Pressure Ranges: _____ (mm Hg)
100/62
Adolescent (12-20 yrs) Normal Blood Pressure Ranges: _____ (mm Hg)
102/80
When measuring the pulse always measure for a full minute in children younger than _____ years
12
Adult Normal Respiration Rate Ranges: _____ to _____ (Breaths/Min)
12 to 20
Adult Normal Blood Pressure Ranges: _____ (mm Hg)
120/80
Adolescent (12-20 yrs) Normal Respiration Rate Ranges: _____ to _____ (Breaths/Min)
15 to 20
School-aged (5-12 yrs) Normal Respiration Rate Ranges: _____ to _____ (Breaths/Min)
15 to 25
Preschooler (3-5 yrs) Normal Respiration Rate Ranges: _____ to _____ (Breaths/Min)
20 to 34
Toddler (1-3 yrs) Normal Respiration Rate Ranges: _____ to _____ (Breaths/Min)
20 to 40
Infant (0-1 yr) Normal Respiration Rate Ranges: _____ to _____ (Breaths/Min)
30 to 60
Normal Pulse Rate Ranges for Adolescent (12-20 yrs) are _____ to _____ (Beats/Min)
60 to 100
Normal Pulse Rate Ranges for adults are _____ to _____ (Beats/Min)
60 to 100
Normal Pulse Rate Ranges for Preschooler (3-5 yrs) are _____ to _____ (Beats/Min)
80 to 120
Normal Pulse Rate Ranges for Infant (0-1 yr) are _____ to _____ (Beats/Min)
80 to 160
Toddler (1-3 yrs) Normal Blood Pressure Ranges: _____ (mm Hg)
90/55
Preschooler (3-5 yrs) Normal Blood Pressure Ranges: _____ (mm Hg)
95/75
Normal Axillary Temperature Ranges: Adult: _____°F, _____°C Child: _____°F, _____°C
96.6-98.6 °F, 36-37 °C 96-98 °F, 35-36 °C
Normal Oral Temperature Ranges: Adult: _____°F, _____°C Child: _____°F, _____°C
97.6-99.6°F, 36.5-37.5°C 97-99°F, 36-37°C
Normal Tympanic Temperature Ranges: Adult: _____°F, _____°C Child: _____°F, _____°C
98.6 °F, 37 °C 98.6 °F, 37 °C
Normal Rectal Temperature Ranges: Adult: _____°F, _____°C Child: _____°F, _____°C
98.6-100.6 °F, 37-38.1 °C 97-99 °F, 37-38 °C
Normal Temporal Temperature Ranges: Adult: _____°F, _____°C Child: _____°F, _____°C
99.6 °F, 37.5 °C 99.6 °F, 37.5 °C
_____ is taken by listening over the apex of the heart with a stethoscope while the patient is usually in a sitting position and leaning forward
Apical pulse
_____ is the force that the blood exerts against the arterial walls
Blood pressure
_____ is a heart rate that is slower than normal, that is, a pulse rate of less than 60 beats per minute - May be normal in some individuals
Bradycardia
A respiratory rate that is lower than normal ( less than 10 breaths per min in adults) is called
Bradypnea
Hypoventilation is
Decreased rate and depth of breathing
What pressure occurs when the heart muscle relaxes
Diastolic pressure
Labored or difficult respiration so are called
Dyspnea
A normal respiratory rate is call
Eupnea
A normal respiratory rate is called _____
Eupnea
True or False. Hypertension is normally diagnosed after a couple elevated readings and the patient or resident is started on medication to help prevent further complications.
F -To diagnose a person with hypertension and start treatment, the person's blood pressure measurements must be taken and recorded over a period of time to show a pattern of constant elevation.
Hyperventilating is
Increased rate and depth of breathing
The difference between the systolic and diastolic pressure is
Pulse pressure
_____: increased body temperature -A person with this is said to be "_____" -The doctor may order an _____ (fever-reducing) drug
Pyrexia febrile antipyretic
_____ is taken by placing fingers over the radial artery (inside of wrist)
Radial pulse
True or False. Obtaining an accurate weight is very important for determining medication doses, especially in children.
T -Many medications given to children are calculated using their weight to determine the correct dose.
True or false. Respirations are controlled by the amount of oxygen in the body
T -The control centers in the brain monitor the carbon dioxide and oxygen content in the blood and adjust the rate and depth of breathing accordingly.
True or False. It's important to note the method you used to obtain the patient's or resident's temperature because of the difference in temperature results.
T -The method used to measure the temperature affects the accuracy of the measurement and should be noted in your recording, but always follow the facilities policy.
True or False. We can tell how hard the heart is beating by measuring the pulse.
T -We can evaluate the force or quality of the pulse known as the pulse amplitude. A weak or thready pulse usually means the heart is having trouble beating.
_____ is a rapid heart rate, or a pulse rate of more than 100 beats per minute for an adult
Tachycardia
A respiratory rate that is higher than normal (greater than 24 per min in adults) is called
Tachypnea
A respiratory rate that is higher than normal is _____
Tachypnea
_____ is the difference between the apical pulse rate and the radial pulse rate; requires two team members measuring pulse at both locations at same time
pulse deficit
Normal respiratory rate: Eupnea • _____ to _____ times a minute for adult • _____ for children and infants
• 16 to 20 times a minute for adult • Higher for children and infants
Factors that Affect Blood Pressure: • _____ • _____ • _____ • _____ • _____ • _____
• Cardiac output • Blood volume • Resistance to blood flow • Age • Gender • Race
Abnormal ranges • _____ • _____ • _____
• Hypertension • Hypotension • Orthostatic hypotension
Factors Affecting Respiration :
• Physical activity • Anxiety, pain, fear • Fever • Infections and diseases of the heart and lungs • Stroke or head injury • Certain medications
When checking the pulse, we look at the • Pulse _____ • Pulse _____ - If irregular is called _____ • Pulse _____
• Pulse rate • Pulse rhythm - Irregular pulse rhythm is called dysrhythmia • Pulse amplitude
Ways of Measuring the Pulse: • _____ • _____ • _____
• Radial pulse • Apical pulse • Pulse deficit
When measuring respiration, we look at • Respiratory _____ • Respiratory _____ • Depth of _____ • Also listen for any abnormal sounds
• Respiratory rate • Respiratory rhythm • Depth of respiration • Also listen for any abnormal sounds
Two blood pressure levels • _____ pressure • _____ pressure - The difference between the two is _____ • Measured in _____ and recorded as a _____
• Systolic pressure • Diastolic pressure - The difference between the two is pulse pressure • Measured in millimeters of mercury (mm Hg) and recorded as a fraction
Abnormal respiratory patterns • _____ • _____ • _____ • _____ • _____
• Tachypnea • Bradypnea • Dyspnea • Hyperventilation • Hypoventilation
Why is it useful to obtain a "baseline" height and weight? -because these measurements provide an insight into the person's overall health and nutritional status -because weight is often used to calculate mediation dosage -because a change in height or weight could provide insight into a change in a patient's or resident's condition -because facility policy usually requires it
-because these measurements provide an insight into the person's overall health and nutritional status -because weight is often used to calculate mediation dosage -because a change in height or weight could provide insight into a change in a patient's or resident's condition
Which of the following are vital signs: -Body Temperature -Weight -Blood Pressure -Height -Respiration -Heart beat
-Body Temperature -Blood Pressure -Respiration -Heart Beat
True or False. Ventilation is the exchange of gases between the body and the environment
F -RESPIRATION is the exchange of gases between the body and the environment.
True or False -Health care professionals refer to certain key measurements that provide essential information about a person's health as vital signs because they are necessary to life
True
This is inserted into the ear canal where it rests near the eardrum and measures the temperature A. Tympanic thermometer B. Glass thermometer C. Temporal artery thermometer D. Electronic or digital thermometer
Tympanic thermometer
This is more often used for children because it allows the temperature to be measured in a safe, quick, and relatively painless manner A. Tympanic thermometer B. Glass thermometer C. Temporal artery thermometer D. Electronic or digital thermometer
Tympanic thermometer
True or False. During the inhalation phase, the chest deflates as the air moves out of the lungs while during the exhalation phase, the chest expands as air is brought into the lungs
F -During the inhalation phase, the chest EXPANDS as air is brought into the lungs while during the exhalation phase, the chest DEFLATES as air moves out of the lungs.
True or false. If a person has been participating in activities that may affect her vital signs, it is not necessary to wait before measuring them.
F -If a person has been participating in activities that may affect her vital signs, it IS necessary to wait before measuring them.
True or false. The radial pulse is measured by listening over the apex of the heart with a stethoscope
F -The APICAL pulse is measured by listening over the apex of the heart with a stethoscope.
True or false. A man's body temperature tends to change more frequently than that of a woman.
F -WOMAN'S body temperature tends to change more frequently than that of a MAN.
Under which circumstances is the apical pulse checked A- when a person has a week or irregular pulse that may be difficult to feel in the radial artery B- when an infant heart rate is to be measured C-when a person has an known heart disease D- in an emergency situation
A- when a person has a week or irregular pulse that may be difficult to feel in the radial artery B- when an infant heart rate is to be measured C-when a person has an known heart disease
True or false. A person who is recovering from rectal surgery may still have a rectal temperature taken
F -A person who is recovering from rectal surgery SHOULD NOT have a rectal temperature taken.
True or false. Although height and weight are not technically vital signs, the nursing assistant is responsible for obtaining and recording these measurements as frequently as vital signs.
F -Although height and weight are not technically vital signs, the nursing assistant is responsible for obtaining and recording these measurements BUT NOT as frequently as vital signs.
True or false. An irregular pulse rhythm is called a pulse amplitude, which means that the pulse rhythm is not smooth and regular, with the same amount of time in between each pulsation
F -An irregular pulse rhythm is called a DYSRHYTHMIA, which means that the pulse rhythm is not smooth and regular, with the same amount of time in between each pulsation.
True or false. Asking for help when one is unsure is a sign of failure or an inability to do one's job
F -Asking for help when one is unsure is NOT a sign of failure or an inability to do one's job.
Which factors can affect a person's pulse rate A- functioning of the central nervous system B- requirements of nutrients and oxygen by tissues C- feelings such as anger, anxiety, illness, pain, fever, and excitement D- medications
A- functioning of the central nervous system B- requirements of nutrients and oxygen by tissues C- feelings such as anger, anxiety, illness, pain, fever, and excitement D- medications
What all can be evaluated when taking a person's pulse? A- how fast the heart is beating B- The pauses of the pulsation and the pauses between them C- how much oxygen is in the blood D- The force or quality of the pulse known as the pulse amplitude or the pulse character
A- how fast the heart is beating B- The pauses of the pulsation and the pauses between them D- The force or quality of the pulse known as the pulse amplitude or the pulse character
True or False. Control centers, called chemoreceptors, are located in the hypothalamus, and in some of the major arteries
F -Control centers, called chemoreceptors, are located in the MEDULLA and in some of the major arteries.
True or false. A weak or thready pulse usually means that the heart is having trouble circulating the blood throughout the body
T
True or false. Heat loss occurs normally through the skin by sweating and by the passing of your urine and feces
T
True or false. The apical pulse rate will be equal to or higher then the radial pulse rate, because it is easier to hear a heartbeat at the source than to feel it
T
True or false. The facilities and agencies will have different policies regarding how vital signs are recorded.
T
True or false. The rate at which the heartbeats is controlled automatically by the bodies central nervous system
T
True or false. stress causes the release of hormones, which increases the rate of metabolism and the heart rate. This increased metabolism may raise body temperature
T
Mr. Harmon frequently experiences orthostatic hypotension. He has been lying in bed, but needs to get up for his regular evening walk. What precaution should you take with Mr. Harmon? a. Allow him to sit for a moment before standing up, to allow time for his body to adjust b. have him ride a wheelchair instead; he doesn't really need the exercise c. first determine his pulse deficit d. have him stand up quicly from his bed
a. Allow him to sit for a moment before standing up, to allow time for his body to adjust
Mr. John is undergoing a surgical procedure. Which one of the following instruments will most likely be used to monitor his blood pressure during the procedure? a. An automated sphygmomanometer b. A manually operated sphygmomanometer c. a manometer d. a stethoscope
a. An automated sphygmomanometer
Human body produces heat as a result of the process of _____
Metabolism
The carotid or femoral arteries may be used to check the pulse during an emergency situation when CPR is being administered.
CPR
What is metabolism? A- the heat lost that occurs normally through the skin. B- The process of readying the body to respond to the source of a given stress C- The state of being more sensitive to environmental temperature changes D- The physical and chemical changes that occur when the cells of the body convert the food that we eat into energy
D -The physical and chemical changes that occur when the cells of the body convert the food that we eat into energy
In this thermometer, the Fahrenheit thermometer is scaled from 94°F to 108°F, while the Celsius thermometer is scales from 34°C to 43°C A. Tympanic thermometer B. Glass thermometer C. Temporal artery thermometer D. Electronic or digital thermometer
Glass thermometer
Most facilities have stopped using this type of thermometer because of the dangerous associated with breakage and spilled mercury A. Tympanic thermometer B. Glass thermometer C. Temporal artery thermometer D. Electronic or digital thermometer
Glass thermometer
Should vital signs be measured and compared at odd hours?
No
Tachycardia is a rapid heart rate, or a pulse rate of more than 100 beats per minute for an adult.
Tachycardia
It is considered to be the least invasive of all of the thermometers available because it does not have to be inserted into any body cavity A. Tympanic thermometer B. Glass thermometer C. Temporal artery thermometer D. Electronic or digital thermometer
Temporal artery thermometer
This device, when passed over a persons forehead, detects the body temperature at numerous points, and then performs a series of calculations on the readings to arrive at the person's peak body temperature A. Tympanic thermometer B. Glass thermometer C. Temporal artery thermometer D. Electronic or digital thermometer
Temporal artery thermometer
You've been asked to measure the rectal temperature of a person using an electric thermometer. The nurses stress that you should remain with the person during the entire procedure. Why is this?
This could stimulate the Vegas nerve, which could cause the persons heart rate and blood pressure to drop
What kind of temperature is taken with a tympanic thermometer -oral temperature -rectal temperature -axillary temperature -tympanic temperature -Temporal artery temperature
Tympanic artery temperature
How can you find the height and weight of a patient that cannot stand for very long periods of time?
With a chair scale
How can you find the height and weight of a patient that weighs more than 250 pounds, is able to get out of bed and walk with help
With an upright scale.
Which vital sign is acceptable to measure without the consent of the patient? a. respiration b. pulse rate c. body temperature d. height and weight
a. Respiratory rate
How long should you measure the pulse rate and respiratory rate of a child younger than 12 years old? a. for 1 minute b. for 30 seconds c. for 2 minutes d. for 5 minutes
a. for 1 minute
If a person's breathing is irregular, what is the best way to obtain an accurate respiratory rate? a. By asking the person to consciously control his respirations b. by watching the rise and fall of a person's chest and counting the number of breaths that occur in 1 minute c. by placing your hand either near the collarbone or on the person's side to feel the breathing d. by watching the rise and fall of a person's chest, counting the number of breaths that occur in 30 seconds, and multiplying that number by 2
b. By watching the rise and fall of a person's chest and counting the number of breaths that occur in 1 minute
The bell is a small rounded surface that is designed to pick up faint sounds like heart murmurs or difficult-to-hear blood pressures.
bell
The diaphragm is the large flat surface that is used to hear loud, harsh sounds like an apical pulse, blood rushing through the arteries, or respiratory sounds.
diaphragm
If a person has a blood pressure that is consistently higher than 140 mm Hg (systolic) and/or 90 mm Hg (diastolic), then that person is said to have _____. -blood pressure -pulse pressure -arteriosclerosis -sphygmomanometer -hypertension
hypertension
Describe the physical and chemical changes that occur when the cells of the body convert the food that we eat into energy
metabolism
How can you find the height and weight of a patient that is in a coma?
tape measure and sling scale
Which of the following statements are true about the Pults? A- with each heartbeat, a wave, or a pulse, of blood passes through the arteries B- The pulse, a throbbing sensation just underneath the skin, can be felt by placing fingers gently over an artery that runs close to the surface of the skin C- you can measure the pulse rate, detect the pulse rhythm, or evaluate the pulse amplitude D- only arteries that run closest to the surface of the skin have a pulse
A- with each heartbeat, a wave, or a pulse, of blood passes through the arteries B- The pulse, a throbbing sensation just underneath the skin, can be felt by placing fingers gently over an artery that runs close to the surface of the skin C- you can measure the pulse rate, detect the pulse rhythm, or evaluate the pulse amplitude
What type of temperature has the least reliable measurements -oral temperature -rectal temperature -axillary temperature -tympanic temperature -Temporal artery temperature
Axillary temperature
What might a change in vital signs indicate? A- of all the activities going on inside the body, one of them has ceased. B- something has put the body out of balance, and the body is attempting to get back that balance. C- regulation of body functions such as temperature and breathing. D- A state of complete physical balance.
B -Something has put the body out of balance, and the body is attempting to get back that balance.
Where might a nursing assistant look to learn how often a particular person's vital signs are to be measured and recorded? A- in the facilities policy manual B- The nursing care plan, the doctors order sheet, or both C- The medication record D- The state registry
B -The nursing care plan, the doctor's order sheet, or both
Which of the following statements is true about taking a persons radial pulse A- should be placed over the radial artery to count the number of pulses B- The middle two or three fingers should be placed over at the radial artery to count the number of pulses that occurred in either 30 seconds or one minute C- although the pulse may be taken at other pulse points, taking the pulse of the radial artery is easiest for the patient or resident D- The radial pulse is a common way to measure the pulse rate
B- The middle two or three fingers should be placed over at the radial artery to count the number of pulses that occurred in either 30 seconds or one minute C- although the pulse may be taken at other pulse points, taking the pulse of the radial artery is easiest for the patient or resident D- The radial pulse is a common way to measure the pulse rate
Why should you know the normal ranges for each vital sign? A- because a person's vital sign measurements may vary over the course of a day. B- because a patient or resident might ask you for this information. C- because knowing normal ranges will allow you to quickly recognize measurements that are not within the range of normal and may indicate a response to illness or injury. D- because blood pressure has to be measured frequently.
C -Because knowing normal ranges will allow you to quickly recognize measurements that are not within the range of normal and may indicate a response to illness or injury.
What is meant by the term body temperature? A- The physical and chemical changes that occur when the cells of the body change the food that we eat into energy B- how rapidly the heartbeats C- how hot the body is; or the difference between the heat produced by the person's body and the heat lost by the person's body. D- muscle movement
C -How hot the body is; or the difference between the heat produced by the person's body and the heat lost by the person's body
Which of the following steps must you not do while using a glass thermometer? A- wash the thermometer with cool water and soap B- rinse the thermometer with cold water C- place the thermometer in hot water D- soak the thermometer in a disinfectant solution
C -Place the thermometer in hot water
What is one way that heat is lost from the body? A- Shivering B- muscle movement C- sweating D- increased metabolism
C -sweating
Which functions are regulated automatically by the body? A- height B- food intake C- body weight D-heart rate, internal temperature of the body, respiratory rate
D -Heart rate, internal temperature of the body, respiratory rate
The thermometer is powered by batteries and a probe is used to measure the temperature. It can be used for oral, rectal, and axillary temperatures A. Tympanic thermometer B. Glass thermometer C. Temporal artery thermometer D. Electronic or digital thermometer
Electronic or digital thermometer
True or false. It is the duty of a nursing assistant to routinely measure and record a person's vital signs and report promptly to the doctor if abnormal changes are detected.
False -It is the duty of a nursing assistant to routinely measure and record patients' or residents' vital signs and report promptly to the NURSE if abnormal changes are detected.
The state of having a body temperature that is much higher than normal is called a _____
Fever
True or false. A patient who is critically ill may be attached to machines that measure his vital signs continuously and displays the results on a monitor.
T
Should vital signs be measured and compared if the person is participating in an activity that may affect her vital signs?
No
Should vital signs be measured and compared to compare with normal values?
No
What kind of temperature is quite accurate but can be most risky -oral temperature -rectal temperature -axillary temperature -tympanic temperature -Temporal artery temperature
Rectal temperature
True or false. A person's vital sign measurements maybe recorded in an electric record.
T
What type of temperature is simple and causes minimal discomfort -oral temperature -rectal temperature -axillary temperature -tympanic temperature -Temporal artery temperature
Oral temperature
The wave of blood sent through the arteries each time the heart beats is a _____
Pulse
A clear plastic disposable cover called a _____ is used to cover the thermometer
Sheath
True or false. A change in a person's normal vitals sign measurements can be a sign of illness
T
What type of temperature is obtained from the person's forehead? -oral temperature -rectal temperature -axillary temperature -tympanic temperature -Temporal artery temperature
Temporal artery temperature
Infants often have immature _____ centers, which mean that their bodies are slow to adjust to changes in external temperature
Thermoregulatory
When taking the temperature rectally, the thermometer could stimulate the _____
Vagus nerve
A mechanical process of moving air in and out of the lungs is _____
Ventilation
Should vital signs be measured and compared before and after certain medications are given?
Yes
Should vital signs be measured and compared before, during, and after a surgical or diagnostic procedure?
Yes
Should vital signs be measured and compared continuously if the person is critically ill?
Yes
Should vital signs be measured and compared every shift or every few hours, when a patient is admitted to a hospital
Yes
Should vital signs be measured and compared if a patient is visiting the doctor
Yes
Should vital signs be measured and compared if the person complains of dizziness, nausea, or pain?
Yes
Should vital signs be measured and compared in an emergency situation?
Yes
Should vital signs be measured and compared once daily or weekly, if admitted to a long-term care facility?
Yes
Should vital signs be measured and compared if the person is not looking or acting like he or she normally does?
Yes?
You have recently become employed at a long-term care facility and are still not comfortable with measuring vital signs. While measuring one of your residence vital signs, you find it to be significantly higher than the normal range indicated by the flow sheet. What should you do?
You should take the measurements again for the sake of accuracy, and then report your findings immediately to the nurse. If you are still not sure that you have taken the vital signs correctly, you should ask for assistance, either from another nursing assistant or a nurse.
What unit of measurement is used to record a person's height? a. inches b. millimeters of mercury c. kilograms d. pounds
a. inches
Resistance to blood flow could be due to _____. -blood pressure -pulse pressure -arteriosclerosis -sphygmomanometer -hypertension
arteriosclerosis
When measuring a child's blood pressure, what determines which cuff size to use? a. the child's developmental stage b. the child's age and weight c. the child's ability to cooperate d. the same cuff is used in adults and children
b. The child's age and weight
What is measured when taking a person's blood pressure? a. Pulse Pressure b. The force that the blood exerts against the arterial wall c. Blood volume d. Cardiac output
b. The force that the blood exerts against the arterial walls
The force that the blood exerts against the arterial walls is known as the _____ -blood pressure -pulse pressure -arteriosclerosis -sphygmomanometer -hypertension
blood pressure.
A heart rate that is slower than normal, that is, a pulse rate of less than 60 beats per minute, is called bradycardia.
bradycardia
A person having difficult or labored breathing is said to be experiencing: a. Eupnea b. tachycardia c. Dyspnea d. Bradypnea
c. Dyspnea
What information should you record when you check respiration in a person? a. the quality of each breath b. the number of times the person breathes each minute c. the regularity with which a person breathes d. All of the above
d. All of the above
What term is used to describe blood pressure that is lower than normal? a. Hypertension b. Bradycardia c. Orthopnea d. Hypotension
d. Hypotension
The difference between the apical pulse rate and the radial pulse rate is known as the pulse deficit.
deficit.
The difference between the systolic and diastolic pressures is known as the_____. -blood pressure -pulse pressure -arteriosclerosis -sphygmomanometer -hypertension
pulse pressure.
The most common method to measure blood pressure is by using a manually operated _____ and a stethoscope -blood pressure -pulse pressure -arteriosclerosis -sphygmomanometer -hypertension
sphygmomanometer
A stethoscope is a device that makes sound louder and transfers it to the listener's ears.
stethoscope
