Chapter 19

Normal pulse in adults

60-100

You are using a glass F thermometer. When you shake it down, the liquid indicator should be below the

94 degree F mark

Which instrument is used to measure blood pressure

A sphygmomanometer

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 him?

Allow him to sit up for a moment before standing up, to allow time for his body to adjust

Mr. John is undergoing a surgical procedure. Which instrument will most likely be used to monitor his blood pressure during the procedure

An automated sphygmomanometer

The least reliable measurement. Must wait 15 minutes after they washed their underarms, or if they applied deodorant/antiperspirant

Axillary temperature

Why should you know the normal ranges for each vital sign?

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

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 medication dosages Because a change in height or weight could provide insight into a change in a patient or residents condition

Key measurements that make up vital signs

Body temperature Blood pressure Respiration Heart beat

If a person's breathing is irregular, what is the best way to obtain an accurate respiratory rate?

By watching the rise and fall of a person's chest and counting the number of breaths that occur in 1 minute

The carotid or femoral arteries may be used to check the pulse during an emergency situation when ________ is being administered

CPR

What could cause a decreased pulse rate? Pain Anger Certain medications Fever

Certain medications

What should you observe when taking a person's pulse? A) The rhythm and regularity of the pulse B) The number of beats per minute C) The strength of the pulse D) All of the above

D) All of the above

Which of the following can cause an inaccurate oral temperature reading: A) The person exercised vigorously 15 minutes prior to having his temperature taken B) The nursing assistant failed to shake down the mercery thermometer C) The person drank a cup of hot coffee 15 minutes prior to having his temperature taken D) All of the above

D) all of the above

T/F: A man's body temperature tends to change more frequently than that of a woman

False

T/F: A person who is recovering from rectal surgery may still have a rectal temperature taken

False

T/F: 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

False

T/F: 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

False

T/F: Control centers, called chemoreceptors are located in the hypothalamus and in some of the major arteries

False

T/F: If a person has been participating in activities that may affect her vital signs, it is not necessary to wait before measuring them

False

T/F: 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

T/F: The radial pulse is measured by listening over the apex of the heart with a stethoscope

False

T/F: Ventilation is the exchange of gases between the body and the environment

False

Which factors can affect a person's pulse rate

Functioning of the CNS Requirements of nutrients and oxygen by tissues Feelings such as anger, anxiety, illness, pain, fever, and excitement Medications

Which functions are regulated automatically by the body?

Heart rate Internal temperature of the body Respiratory rate

Regulated automatically by the body

How fast the heart beats The internal temperature of the body The rate at which a person breathes

What can be evaluated when taking a person's pulse

How fast the heart is beating The pattern of the pulsations and the pauses between them The force of quality of the pulse known as the pulse amplitude of the pulse character

What is meant by the term body temperature?

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

What term is used to describe blood pressure that is lower than normal

Hypotension

Simple and causes minimal discomfort. Wait 15-30 minutes minutes after eating, drinking, smokes, or chews fun

Oral temperature

Which of the following steps must you NOT do while using a glass thermometer?

Place the thermometer in hot water

Quite accurate but can be most risky

Rectal temperature

If you notice a significant change in a person's vital signs, what should you do

Report the change to the nurse immediately

One of your patients has a temp of 98.8, a pulse rate of 80 ppm, and a respiratory rate of 30 breaths/min. Which should be reported to the nurse immediately?

Respiratory rate

Which vital sign is acceptable to measure without the consent of the patient?

Respiratory rate

What might a change in a vital sign indicate?

Something has put the body out of balance, and the body is attempting to get back that balance

What is one way that heat is lost from the body?

Sweating

Obtained from the person's forehead. Least invasive of all the thermometers available.

Temporal artery temperature

What is measured when taking a person's blood pressure

The force that the blood exerts

Which of the following statements is true about taking a person's radial pulse

The middle two or three fingers should be placed over the radial artery to count the number of pulses that occur in either 30 seconds or 1 minute Although the pulse may be taken at other pulse points, thing the pulse at the radial artery is easiest for the patient or resident The radial pulse is a common way of measuring the pulse rate

Where might a nursing assistant look to learn how often a particular person's vital signs are to be measured and recorded?

The nursing care plan, the doctor's order sheet, or both

Which one of the following conditions would prevent you from taking an oral temperature Diarrhea Mastectomy Unconscious 10 year old

The person is unconscious

What is metabolism?

The physical and chemical changes that occur when the cells of the body convert the food that we eat into energy

What information should you record when you check for respiration in a person?

The quality of each breath The number of times the person breathes each minute The regularity with which a person breathes

T/F: A change in a person's normal vital sign measurements can be a sign of illness

True

T/F: A patient who is critically ill may be attached to machines that measure his vital signs continuously and display the results on a monitor

True

T/F: A person's vital sign measurements may be recorded in an electronic record

True

T/F: A weak or thready pulse usually means that the heart is having trouble circulating blood throughout the body

True

T/F: Facilities and agencies will have different policies regarding how vital signs are recorded

True

T/F: 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

T/F: Heat loss occurs normally through the skin by sweating and by the passing of urine and feces

True

T/F: Stress causes the release of hormones which increase the rate of metabolism and the heart rate. This increased metabolism may raise the body temperature

True

T/F: The apical pulse rate and the radial pulse rate should be the same in any single person. However, occasionally the heart does not beat strongly enough to send enough blood through the arteries with each beat, so it might be may be heard over the apex of the heart but not in the wrist. This is known as the pulse deficit.

True

T/F: The apical pulse rate will be equal to or higher than the radial pulse rate, because it is easier to hear a heartbeat at the source than to feel it

True

T/F: The rate at which the heart beats is controlled automatically by the body's central nervous system

True

T/F: Waste products such as carbon dioxide are created as a result of normal cellular function, namely metabolism

True

Taken with a thermometer in ear. Often used for children.

Tympanic temperature

Under which circumstances is the apical pulse checked

When a person has a weak or irregular pulse that may be difficult to feel in the radial artery When an infant's heart rate is to be measured When a person has known a heart disease

Statements that are true about the pulse

With each heart beat, a wave, or pulse, of blood passes through the arteries 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 You can measure the pulse rate, detect the pulse rhythm, or evaluate the pulse amplitude

A stethoscope is used to determine the:

apical pulse rate

Resistance to blood blow could be due to _______

arteriosclerosis

When counting respirations you should

avoid telling the person what you are going to do

The ________ is a small rounded surface that is designed to pick up faint sounds like heart murmurs or difficult to hear blood pressures

bell

The force that the blood exerts against the arterial walls is known as the _________

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

The ______________ 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

What is the pressure exerted by the blood flowing through the arteries when the heart muscle relaxes

diastolic pressure

A person having difficult or labored breathing is said to be experiencing

dyspnea

Irregular pulse rhythm

dysrhythmia

Normal respiratory rate

eupnea (12-20 a minute)

A person who has an increased body temperature is said to have a fever or be

febrile

The state of having a body temperature that is much higher than normal is called ____________

fever

Tachypnea

greater than 24 breaths/min

If a person has a blood pressure that is consistently higher than 140 mm Hg (systolic) and/or 90 mm Hg (diastolic), that that person is said to have ______________

hypertension

Bradypnea

less than 10 breaths/min

The human body produces heat as a result of the process of __________

metabolism

Force or quality of the pulse

pulse amplitude

Th difference between the apical pulse and the radial pulse rate is known as the _________

pulse deficit

The difference between the systolic and diastolic pressures is known as the ________

pulse pressure

Number of pulsations that can be felt in 1 minute

pulse rate

Pattern of the pulsations and the pauses between them

pulse rhythm

The most common site for counting the pulse is the

radial artery

A clear plastic disposable cover called a ____________ is used to cover the thermometer

sheath

The most common method to measure blood pressure is by using a manually operated _________ and a stethoscope

sphygmomanometer

A ___________ is a device that makes sound louder and transfers to the listeners ears

stethoscope

___________ is a rapid heart rate, or a pulse rate of more than 100 beats per minute for an adult

tachycardia

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