p.20
Pulse Rate and Quality Assessment
Where is the radial pulse located?
On the wrist, typically felt on the thumb side.
p.14
Blood Pressure Measurement and Interpretation
What is the purpose of a blood pressure cuff?
To measure blood pressure in patients.
p.10
Korotkoff's Sounds in Blood Pressure Assessment
What are Korotkoff's sounds?
Sounds heard over an artery during cuff deflation.
p.9
Blood Pressure Measurement and Interpretation
What does diastolic pressure reflect?
Arteriolar or peripheral vascular resistance.
p.23
Factors Influencing Vital Signs
How does the sympathetic nervous system affect blood pressure?
It causes vasoconstriction, increased heart rate, and increased cardiac contractility, leading to elevated blood pressure.
p.25
Respiration Mechanics and Patterns
Which muscles are primarily used for breathing?
Diaphragm and intercostal muscles.
p.14
Blood Pressure Measurement and Interpretation
What types of patients can use the dual tube blood pressure cuff mentioned?
Neonates, infants, children, and adults.
p.15
Blood Pressure Measurement and Interpretation
What sounds is the bell of the stethoscope used to auscultate?
Lower pitch sounds such as heart sounds and blood pressure.
p.9
Blood Pressure Measurement and Interpretation
What information does pulse pressure provide?
Cardiac function and blood volume.
p.3
Vital Signs and Their Importance
What are vital signs?
Objective data that reflect the body's physiological status.
p.29
Temperature Regulation and Measurement
What can increase the set point of the temperature-regulating center to cause fever?
Disease, inflammation, brain lesions, or degenerating tissue.
p.16
Blood Pressure Measurement and Interpretation
What is secondary hypertension?
Hypertension caused by renal or endocrine diseases.
p.3
Vital Signs and Their Importance
What are the five vital signs?
1. Blood pressure 2. Pulse 3. Temperature 4. Respiration 5. Pain assessment.
p.6
Vital Signs and Their Importance
When should vital signs be measured during surgical procedures?
Before, during, and after a surgical procedure or invasive diagnostic procedure.
p.7
Factors Influencing Vital Signs
What factor influences systolic pressure?
Cardiac output, which is the force of heart contraction.
p.12
Blood Pressure Measurement and Interpretation
What is the purpose of the bulb in a sphygmomanometer?
It is used to pump up the air bladder.
p.17
Pulse Rate and Quality Assessment
How is pulse measured?
By counting the number of heartbeats per minute (bpm).
p.16
Blood Pressure Measurement and Interpretation
What is primary or essential hypertension defined as?
Blood pressure over 140/90 mmHg.
p.4
Factors Influencing Vital Signs
How does age influence vital signs?
Temperature fluctuation is common in newborns and elderly clients. As age increases, respirations and heart rate decrease, while blood pressure may increase.
p.23
Factors Influencing Vital Signs
What is the role of baroreceptors in the circulatory system?
They transmit signals to the vasomotor center to stimulate the sympathetic nervous system to divert blood flow to vital organs.
p.28
Temperature Regulation and Measurement
What is core temperature maintained by?
When heat production equals heat loss.
p.31
Pain Assessment and Its Subjectivity
How do individuals differ in their experience of pain?
People have different pain thresholds, tolerances, and reactions to pain.
p.31
Pain Assessment and Its Subjectivity
Why should pain be considered subjective?
Because it varies greatly from person to person and should not be challenged.
p.23
Factors Influencing Vital Signs
What part of the nervous system controls the pulse?
The autonomic nervous system in the medulla oblongata.
p.5
Factors Influencing Vital Signs
What is the effect of chronic pain on pulse rate?
Chronic pain decreases pulse rate due to parasympathetic stimulation.
p.31
Pain Assessment and Its Subjectivity
What is the primary function of the sensation of pain?
To alert us to injury or illness and serve as a protective mechanism.
p.30
Temperature Regulation and Measurement
What factors can cause variations in body temperature?
Age, time of day, amount of exercise, and environmental temperature extremes.
p.23
Factors Influencing Vital Signs
How does autoregulation affect blood flow in tissues?
Blood flow is adjusted according to the oxygen needs of different tissues.
p.6
Vital Signs and Their Importance
What should be done before measuring vital signs?
Ensure equipment is functioning well for accurate findings.
p.7
Factors Influencing Vital Signs
What determines diastolic pressure?
Peripheral vascular resistance, influenced by the autonomic nervous system.
p.6
Vital Signs and Their Importance
When should vital signs be measured in relation to nursing interventions?
Before, during, and after nursing interventions influencing a vital sign.
p.23
Factors Influencing Vital Signs
What is the effect of the parasympathetic nervous system on heart rate and blood pressure?
It causes vasodilation and reduced heart rate, resulting in decreased blood pressure.
p.15
Blood Pressure Measurement and Interpretation
What does the stethoscope attach to?
Rubber tubing that leads to two hollow metal tubes with earpieces.
p.18
Pulse Rate and Quality Assessment
What determines the quality of the pulse?
The amount of blood pumped through the peripheral arteries.
p.29
Temperature Regulation and Measurement
How can dehydration affect body temperature?
It can cause fever due to lack of available fluid for perspiration.
p.12
Blood Pressure Measurement and Interpretation
What does the cuff in a sphygmomanometer do?
It covers the bladder and wraps around the extremity.
p.4
Factors Influencing Vital Signs
How do gender differences affect temperature fluctuations?
Women experience greater temperature fluctuations than men, likely due to hormonal changes.
p.28
Temperature Regulation and Measurement
What mechanisms contribute to heat loss in the body?
Radiation, evaporation, and conduction.
p.28
Temperature Regulation and Measurement
What stimulates heat production in the body?
Shivering and increased cellular metabolism.
p.6
Factors Influencing Vital Signs
What can cause predictable changes in vital signs?
Some diseases or treatments.
p.21
Pulse Rate and Quality Assessment
What is the location of the dorsalis pedis pulse?
Along the top of the foot, between the extension tendons of the great and first toe.
p.5
Factors Influencing Vital Signs
How can medications influence vital signs?
Some medications can directly or indirectly alter temperature, pulse, respirations, and blood pressure.
p.5
Factors Influencing Vital Signs
How does acute pain affect vital signs?
It leads to sympathetic stimulation, increasing heart rate, respiratory rate, and blood pressure.
p.13
Blood Pressure Measurement and Interpretation
What is the recommended cuff size for a normal adult?
Normal adult-size cuff (13).
p.6
Vital Signs and Their Importance
When should vital signs be measured upon admission?
On admission to the healthcare facility.
p.29
Temperature Regulation and Measurement
What are common signs of fever?
Perspiration, warm body to touch, chills, flushed face, increased pulse and respirations, dry skin, malaise, fatigue, and convulsions in children.
p.29
Temperature Regulation and Measurement
What happens when body temperature falls below 35 °C?
The client experiences hypothermia, complains of being cold, shivers, and has cool extremities.
p.6
Vital Signs and Their Importance
Why is it important to review a client’s previous vital signs?
To establish a baseline for comparison.
p.6
Factors Influencing Vital Signs
What client information is important to know before measuring vital signs?
Client’s medical history, therapies, and prescribed medications.
p.21
Pulse Rate and Quality Assessment
Where is the temporal pulse located?
Over the temporal bone of the head, above and lateral to the eye.
p.8
Factors Influencing Vital Signs
Which hormones and enzymes influence blood pressure?
Epinephrine, renin, angiotensin cause vasoconstriction; histamine and acetylcholine cause vasodilation.
p.22
Pulse Rate and Quality Assessment
What is tachycardia?
A pulse rate over 100 beats/min.
p.8
Factors Influencing Vital Signs
What is the effect of increased PaCO2 and decreased pH on the vasomotor center?
They directly stimulate the vasomotor center, causing increased peripheral vascular resistance.
p.9
Blood Pressure Measurement and Interpretation
What does systolic pressure indicate?
The condition of the heart and great arteries.
p.9
Blood Pressure Measurement and Interpretation
What is pulse pressure?
The difference between systolic and diastolic pressure.
p.17
Pulse Rate and Quality Assessment
What causes the transient expansion of peripheral arteries?
The forceful ejection of blood by the left ventricle.
p.5
Factors Influencing Vital Signs
How does circadian rhythm influence vital signs?
It controls sleep patterns and influences blood pressure and temperature, which are lowest in the morning and peak in the evening.
p.30
Temperature Regulation and Measurement
How does axillary temperature compare to oral temperature?
Approximately 0.5 °C lower.
p.27
Respiration Mechanics and Patterns
What is tachypnea?
Regular but shallow respiration above 24 breaths per minute.
p.25
Respiration Mechanics and Patterns
What defines tachypnea?
Over 24 breaths per minute.
p.25
Respiration Mechanics and Patterns
What defines bradypnea?
Below 10 breaths per minute.
p.16
Factors Influencing Vital Signs
What factors can contribute to orthostatic hypotension?
Antihypertensive drugs and prolonged immobility.
p.7
Factors Influencing Vital Signs
How does blood volume affect blood pressure?
Increased blood volume raises both systolic and diastolic blood pressure, and vice versa.
p.21
Pulse Rate and Quality Assessment
Where can the carotid pulse be found?
Along the medial edge of the sternocleidomastoid muscle in the neck.
p.24
Respiration Mechanics and Patterns
Where are peripheral receptors located that respond to oxygen levels in the blood?
In the carotid body and the aortic arch.
p.5
Factors Influencing Vital Signs
What effect do narcotic analgesics have on vital signs?
They can depress the rate and depth of respirations and lower blood pressure.
p.15
Blood Pressure Measurement and Interpretation
What sounds does the diaphragm of a stethoscope auscultate?
High-pitched sounds such as lung sounds.
p.15
Blood Pressure Measurement and Interpretation
What should be noted about some stethoscopes regarding the bell?
Not all stethoscopes have a bell, so the diaphragm is used instead.
p.12
Blood Pressure Measurement and Interpretation
What must the gauge needle indicate before using a blood pressure cuff?
The needle must be on zero.
p.25
Respiration Mechanics and Patterns
What is the normal breathing pattern for an adult at rest?
12-18 breaths per minute.
p.28
Temperature Regulation and Measurement
What is the usual variation range of core temperature?
Within 0.5 °C, except in febrile illness.
p.28
Temperature Regulation and Measurement
How does the thermostat adjust body temperature?
By adjusting heat production and heat loss.
p.24
Respiration Mechanics and Patterns
What controls the rate and depth of breathing?
The respiratory center in the medulla of the brain and the level of carbon dioxide in the blood.
p.8
Factors Influencing Vital Signs
What happens when PaO2 decreases?
It stimulates chemoreceptors, which in turn stimulate the vasomotor center.
p.22
Pulse Rate and Quality Assessment
What conditions are associated with tachycardia?
Stressful conditions, hypoxia, exercise, and fever.
p.13
Blood Pressure Measurement and Interpretation
What type of cuff should be used for an obese adult?
A large cuff or measure blood pressure on the leg.
p.12
Blood Pressure Measurement and Interpretation
What is the function of the inflatable rubber bladder in a sphygmomanometer?
It holds air to measure blood pressure.
p.17
Factors Influencing Vital Signs
What factors influence pulse rate?
Elasticity of larger vessels, blood volume, blood viscosity, and arteriolar and capillary resistance.
p.28
Temperature Regulation and Measurement
What is the role of the hypothalamus in body temperature regulation?
It regulates temperature control as a homeostatic function.
p.18
Pulse Rate and Quality Assessment
What is a bounding pulse?
A strong and easy to feel pulse.
p.29
Temperature Regulation and Measurement
How does low temperature affect cellular metabolism and heat production?
It is depressed at 34 °C and lost if below 29 °C.
p.8
Factors Influencing Vital Signs
What effect does blood viscosity have on blood flow velocity?
Increased viscosity raises resistance to blood flow.
p.21
Pulse Rate and Quality Assessment
Where is the radial pulse located?
On the thumb side of the forearm at the wrist.
p.20
Pulse Rate and Quality Assessment
How do you locate the common carotid pulse?
Place the index and middle finger just to the side of the Adam's apple in the soft hollow area.
p.14
Blood Pressure Measurement and Interpretation
What is the significance of using a large adult blood pressure cuff?
To ensure accurate blood pressure readings for larger individuals.
p.27
Respiration Mechanics and Patterns
What characterizes bradypnea?
Slow, regular respirations less than 10 breaths per minute.
p.27
Respiration Mechanics and Patterns
What is hyperpnea?
An abnormal increase in depth and rate of breathing.
p.31
Pain Assessment and Its Subjectivity
How can levels of pain be assessed?
By asking the person to rate their pain on a scale from 0 to 10.
p.31
Pain Assessment and Its Subjectivity
What does a pain rating of 10 represent?
The worst pain imaginable.
p.21
Pulse Rate and Quality Assessment
Where can the popliteal pulse be found?
Behind the knee in the popliteal fossa.
p.12
Blood Pressure Measurement and Interpretation
What are the main components of a sphygmomanometer?
An inflatable rubber bladder, a cuff, rubber tubing, a gauge, and a squeezable bulb.
p.16
Clinical Implications of Vital Signs
What causes primary hypertension?
Progressive arteriosclerosis and loss of elasticity in arterial walls.
p.18
Pulse Rate and Quality Assessment
What does a thready pulse indicate?
A weak pulse that is hard to determine the flow.
p.18
Pulse Rate and Quality Assessment
Where can arterial pulses be felt?
Over arteries close to the body surface and over a firm surface that supports the artery.
p.8
Factors Influencing Vital Signs
How does aging affect the elasticity and distensibility of arteries?
They decrease, resulting in increased systolic pressure and slightly increased diastolic pressure.
p.18
Pulse Rate and Quality Assessment
What is a pulse deficit?
The difference when the radial pulse rate is less than the apical rate.
p.17
Pulse Rate and Quality Assessment
What does pulse indicate?
The heart's rate and rhythm.
p.27
Respiration Mechanics and Patterns
Describe Cheyne-Stokes respiration.
Periods of apnea with a cycle of deeper and faster respirations followed by a slower rate.
p.30
Temperature Regulation and Measurement
How does rectal and ear canal temperature compare to oral temperature?
Approximately 0.5 °C higher.
p.23
Factors Influencing Vital Signs
What stimulates baroreceptors in the carotid sinus and aortic arch?
Decreased circulating volume.
p.12
Blood Pressure Measurement and Interpretation
What is the purpose of the screw valve in a sphygmomanometer?
It allows filling or emptying the air from the bladder.
p.7
Blood Pressure Measurement and Interpretation
What is blood pressure (BP)?
The measurement of the pressure or tension of the blood pushing against the walls of arteries in the vascular system.
p.16
Clinical Implications of Vital Signs
What symptoms are associated with orthostatic hypotension?
Dizziness, blurring or loss of vision, and fainting.
p.24
Respiration Mechanics and Patterns
What is respiration?
The process of bringing oxygen to body tissues and removing carbon dioxide.
p.18
Pulse Rate and Quality Assessment
What affects the amplitude of a pulse?
The degree of filling in the artery during systole and emptying during diastole.
p.18
Pulse Rate and Quality Assessment
When is the pulse typically weak?
In cases of weak cardiac contractions, incomplete ventricular filling, and aortic stenosis.
p.22
Pulse Rate and Quality Assessment
Why might tachycardia occur in congested heart failure?
As a compensatory response to poor tissue oxygenation.
p.25
Respiration Mechanics and Patterns
What are accessory muscles involved in respiration?
Abdominal muscles, sternocleidomastoid, trapezius, and scalene.
p.17
Clinical Implications of Vital Signs
What happens to the peripheral pulse if cardiac output is reduced?
The peripheral pulse becomes weak.
p.31
Pain Assessment and Its Subjectivity
What factors influence the levels of pain experienced?
Physical pathology, cultural and social factors, expectations, mood, and perceptions of control.
p.16
Clinical Implications of Vital Signs
What is orthostatic hypotension?
A drop in systolic (> 20 mmHg) or diastolic blood pressure (> 10 mmHg) upon standing.
p.11
Korotkoff's Sounds in Blood Pressure Assessment
What are Korotkoff's sounds?
Five distinct sounds that represent different stages of returning blood flow.
p.4
Factors Influencing Vital Signs
Which race is more prone to increased blood pressure?
African Americans are more prone to increased blood pressure due to salt sensitivity or higher blood cholesterol levels.
p.6
Vital Signs and Their Importance
When should vital signs be measured if a client reports physical distress?
When the client reports nonspecific symptoms of physical distress.
p.22
Pulse Rate and Quality Assessment
How does the heart rate differ between genders?
Rates are slightly faster in women.
p.22
Pulse Rate and Quality Assessment
What is bradycardia?
A pulse rate below 60 beats/min.
p.25
Respiration Mechanics and Patterns
How does the chest normally expand during breathing?
Symmetrically without rib flaring or retractions.
p.22
Pulse Rate and Quality Assessment
What pathologic conditions can produce bradycardia?
Decreased thyroid activity, hyperkalemia, heart blocks, and increased intracranial pressure (ICP).
p.24
Respiration Mechanics and Patterns
What happens during inspiration?
The diaphragm descends, external intercostal muscles contract, and the chest expands to allow air into the tracheobronchial tree.
p.21
Pulse Rate and Quality Assessment
What is the location of the brachial pulse?
In the groove between the biceps and triceps muscles at the antecubital fossa.
p.8
Factors Influencing Vital Signs
What do chemoreceptors in the aortic arch and carotid sinus respond to?
Changes in PaO2, PaCO2, and pH.
p.21
Pulse Rate and Quality Assessment
What is the location of the femoral pulse?
Below the inguinal ligament, midway between the symphysis pubis and the anterior superior iliac spine.
p.4
Factors Influencing Vital Signs
What is the average blood pressure for newborns and adults?
<p>newborns: 65/42 mmHg.</p><p>adults: 120/80 mmHg.</p>
p.4
Factors Influencing Vital Signs
What is the average respiration rate for newborns and adults?
<p>newborns: 32 breaths per minute.</p><p>adults: 16 breaths per minute.</p>
p.4
Factors Influencing Vital Signs
What is the average heart rate for newborns and adults?
<p>newborns: 140 beats per minute.</p><p>adults: 80 beats per minute.</p>
