BSN Nursing Assessment Techniques Quiz

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18 Questions

What is the main purpose of taking vital signs?

To measure the client's body temperature, pulse rate, respiratory rate, and blood pressure

Which body systems are reflected in the data provided by vital signs?

Cardiovascular, peripheral vascular, neurologic, and respiratory systems

What is considered the 5th vital sign in healthcare?

Pain

Which type of temperature fluctuates in response to the environment?

Surface temperature

What is the normal range for body temperature in Celsius?

36.5 - 37.7 °C

Which step is considered the first in the physical examination process?

Measurement of vital signs

What is the first step Eloisa should take in the assessment according to the text?

Discuss normal breathing rates

Which of the following best describes how to palpate a peripheral pulse as per the text?

Place the first two fingers with moderate pressure

What does it mean if a patient's breathing is described as 'diaphragmatic' according to the text?

Breathing involves contraction of the diaphragm

Which term refers to the interchange of oxygen and carbon dioxide between the alveoli and pulmonary blood?

External respiration

What characterizes an elastic artery as described in the text?

Contains collagen and elastin for stretchability

What should Eloisa do after taking the patient's pulse as per the text?

Begin counting respirations

Where is the popliteal pulse located?

Behind the knee in the popliteal fossa

Which term is used to describe a strong pulse with a volume higher than normal?

Bounding

What does bradycardia refer to?

Less than 60 bpm

What indicates arterial wall elasticity?

Volume of blood pushed against the artery wall during ventricular contraction

Where is the dorsalis pedis pulse located?

On the dorsum of the foot

What does a thready pulse indicate?

Diminished strength and lacks fullness

Study Notes

Assessing Vital Signs

  • Begin the assessment by speaking with the client about their normal pulse rate.
  • Palpate a peripheral pulse by placing the first two fingers on the pulse point with moderate pressure.
  • Count the pulse rate for a full minute, noting the regularity (rhythm).

Pulse

  • Normal pulse rate: 60-100 bpm.
  • Bradycardia: less than 60 bpm.
  • Tachycardia: greater than 100 bpm.
  • Rhythm: pattern of beats (regular/irregular).
  • Pulse volume: strength or size of the pulse.
  • Bounding/full pulse: strong pulse, volume higher than normal.
  • Thready/weak pulse: diminished strength, lacks fullness.
  • Imperceptible pulse: cannot be felt or heard.

Breathing and Ventilation

  • Normal breathing is active and passive.
  • Women breathe thoracically, while men and young children breathe diaphragmatically.
  • Assess breathing after taking pulse, while still holding the hand, so the patient is unaware.
  • Ventilation: movement of air in and out of the lungs.
  • Symmetrical breathing: sides of the chest normally rise and fall together.
  • Asymmetrical breathing: rise and fall are not together.
  • External respiration: interchange of O2 and CO2 between the alveoli and the pulmonary blood.
  • Internal respiration: interchange of O2 and CO2 between the circulating blood and body tissues.

Arteries

  • An artery is straight, smooth, soft, and pliable/elastic.
  • Elastic artery contains collagen and elastin filaments, which gives it the ability to stretch in response to each pulse.
  • Artery wall elasticity reflects expansibility and deformities.

Pulse Locations

  • Popliteal pulse: located behind the knee in the popliteal fossa with the patient's knee flexed.
  • Dorsalis pedis pulse: located on the dorsum of the foot with the foot plantar flexed.
  • Palpate for this pulse halfway between the middle of the patient's ankle and the space between the great toe and the second toe.
  • Posterior tibial pulse: located on the inner side of the ankle slightly below the medial malleolus.

Respiration and Blood Pressure

  • Absence of bilateral equality affects blood pressure.
  • Each time the heart beats, pressure is created that may indicate cardiovascular disorder.

Terminologies

  • Rate: number of beats per minute (bpm).
  • Rhythm: pattern of beats (regular/irregular).
  • Dysrhythmia or arrhythmia: random, irregular beats or predictable pattern of irregular beats.

Assessing Pulse Rate

  • Allow 5 minutes of rest before taking vital signs.
  • The goal is to completely meet the patient's needs.

Temperature

  • Normal temperature: 36.5 - 37.7 °C.
  • Balance between the heat produced by the body and heat lost from the body.
  • Two kinds of temperature: surface temperature and core temperature.
  • Surface temperature fluctuates in response to the environment.
  • Core temperature remains relatively constant.
  • Temperature is lowest in the morning (4am-6am) and highest during the evening.

Vital Signs

  • Temperature (T), pulse (P), and respiratory (R) rates, and blood pressure (BP) are the "cardinal signs".
  • The "taking of vital signs" refers to the measurement of these signs.
  • Vital signs are the first step in the physical examination.
  • Clinical measurements that provide data that reflect the status of several body systems, including cardiovascular, peripheral vascular, neurologic, and respiratory systems.
  • Pain is considered the 5th vital sign.

Test your knowledge on nursing assessment techniques including palpating peripheral pulses and counting pulse rate. Focus on assessing normal breathing patterns in different demographics.

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