Nursing Assistant - A nursing process approach (Vital Signs)

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Temperature is less stable in

Children

Dyspnea

Difficult breathing

The most accurate temperature is taken with the tympanic thermometer

False

Tachypnea

Rapid respiration

When using an overbed scale, the patient's body must be free of the bed

True

sphygmomanometer

blood pressure apparatus

Blood pressure is raised by

exercise

Exhalation

expiration

Tachycardia

faster heart rate

The earpieces of the stethoscope should be pointed _________________as they are placed in the ears

forward

High blood pressure is known as

hypertension

Postural_______________is a sudden decrease in blood pressure when changing position

hypotension

Accelerated

increased/ sped up

dyspnea

is how we chart difficult respirations

Blood pressure is lowered when weight is

lost

rales

moist respirations

Apnea

periods of no respiration

apical

pulse rate will be the second you count

tachypnea

rapid respiration

rhythm

regularity

Rate

speed

elasticity

stretch

The closing of the heart valves is heard as the _______ sounds

systolic

radial

the pulse rate you will count from

A patient who cannot get out of bed cannot be measured

False

Always apply gloves before taking a temporal artery temperature.

False

Blood pressure taken over arteries closer to the heart will be lower then those taken over arteries farther from the heart.

False

Depressant drugs elevate the blood pressure

False

Disconnect the catheter bag before weighing the patient

False

Exercise decreases blood pressure

False

Gently pull the ear pinna back and down before inserting the tympanic thermometer in an adult.

False

Hold the temporal artery thermometer in place for 3 minute

False

Ill-fitting dentures have no effect on weight

False

Measuring the temperature in the groin area given the most accurate indication of body temperature

False

Only temperature variations of more than 5 F should by reported to the nurse

False

Orthostatic hypotension is most common in middle-aged adults

False

Pulses differ when counted at different pulse sites

False

The axillary temperature of a patient will register approximately one degree higher than his oral temperature.

False

The forearm is a good alternate location for taking blood pressure

False

The large lines on the blood pressure gauge are in increments of 20 millimeters of mercury pressure.

False

The oral thermometer should remain in place for 1 minute.

False

The probe of an electronic thermometer covered with a red sheath for rectal use.

False

The tympanic temperature reading is the most accurate.

False

To measure a patient who is confined to bed, first help her assume the left Sims' position

False

To measure a rectal temperature, the patient is best positioned on her back.

False

Wait 5 minutes after the patient has taken hot liquids to measure an oral temperature.

False

The normal temporal artery temperature reading is 97.2 F

False - 99 F

A pulse is best counted using the thumb placed over the artery

False - Any of your three middle fingers.

The temporal artery is deep within the body core.

False - Its actually close to the surface

The pulse site used most often is the carotid artery

False - Its the radial artery

Cheyne-Stokes respirations are deep and regular.

False - They are a period of dyspnea followed by periods of apnea

The pulse rate of an infant is 110 to 130 bpm

False = 120-160 bpm

Hypertension

High blood pressure

Which way do we measure weight at Munson?

Kilogram

Diastolic

Lowest blood pressure reading

Bradycardia

Slow pulse

stertorous

Snoring types of respiration

Vital signs include

Temperature, pulse, respiration, and blood pressure.

96.8 F is an average oral temperature

True

A blood pressure below 100/60 suggests hypotension

True

A pulse deficit results when there is a difference between the apical and radial pulses.

True

Always check the overbed scale for needed repairs before use.

True

Always wipe the axillary area before placing a thermometer

True

An apical pulse should be counted in children

True

Many health care professionals depend on the accuracy of patient weight and height measurements.

True

Mucus in the air passages causes crackles

True

Patients and residents can and often do develop malnutrition during a stay in a health care facility

True

Reading taken with a plastic thermometer may not be entirely accurate

True

Stethoscope earpieces should be cleaned both before and after use.

True

Temperature is the measurement of body heat.

True

The most common method of measuring the temperature of a cooperative adult is by mouth

True

The respiratory system rids the body of excess carbon dioxide

True

The scale used most often to weigh ambulatory patients in health care facilities is the upright scale

True

The temporal artery and tympanic thermometers are ideal for taking temperatures of patients using oxygen.

True

The volume of blood in the circulatory system affects the blood pressure

True

To accurately measure blood pressure, you will need both a manual BP cuff and a stethoscope

True

Using a blood pressure cuff of the wrong size will give an inaccurate reading

True

Weight loss is a common problem in health care facilities because of physical and mental conditions

True

When charting an axillary temperature, always print AX after the reading

True

When measuring a blood pressure, always keep the gauge at eye level.

True

All rectal thermometers should be lubricated before insertion.

True.

The pulse is the pressure of blood against the arterial wall.

True.

There may be times when a temperature has to be measured in the groin area

True.

When using an electronic thermometer, you should not touch the tip of the probe sheath with you fingers.

True.

The upright scale is used to weigh

ambulatory patients

A temporal artery temperature might be expected to be slightly higher than

an oral temperature and about the same rectal temperature.

brachial

artery most commonly used to determine blood pressure

cyanosis

bluish discoloration to the skin

Which way do we measure height at Munson?

centimeters


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