Medical Surgical Nursing Vital Signs Discussion

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Which type of thermometer captures heat emitted by the skin over the temporal artery?

Temporal artery thermometer (correct)
Tempa-Dot thermometer
Disposable single-use thermometer
Tympanic membrane thermometer

What affects the accuracy of readings from the temporal artery thermometer?

Patient's state of consciousness
Amount of pain
Technique and cleanliness of the device (correct)
Facility policy

Under what condition should oral temperature not be taken?

When the patient is able to close their mouth around the temperature probe
After the patient has taken hot or cold foods or liquids
When waiting 15-30 minutes is not possible
In patients with a broken jaw that is wired closed (correct)

How long should the probe remain in the sublingual pocket for oral temperature measurement?

1 minute (C) Signup and view all the answers

What is a characteristic of disposable single-use thermometers?

They measure body temperature within 10 seconds (B) Signup and view all the answers

Which route is a frequent method for estimating core body temperature?

Tympanic membrane (B) Signup and view all the answers

What is the definition of Vital Signs?

They reflect the health status of a person and often vary by age (A) Signup and view all the answers

Which of the following is NOT a component of Vital Signs?

Mental alertness (A) Signup and view all the answers

What is the balance that temperature represents in relation to Vital Signs?

Balance between heat produced and lost (D) Signup and view all the answers

Why are Vital Signs important in patient care?

They help identify normal patterns for patients and changes in patient status (B) Signup and view all the answers

What is the main purpose of taking Vital Signs?

To monitor normal patterns for patients and detect changes in patient status (B) Signup and view all the answers

Why are Vital Signs considered an important component of health care?

Because they reflect the health status of a person and often vary by age (C) Signup and view all the answers

What is the significance of Phase I of the Korotkoff sounds?

It marks the beginning of faint tapping sounds and indicates systolic pressure (C) Signup and view all the answers

What is the auscultatory gap as mentioned in the text?

The temporary disappearance of sounds in Phase I and during Phase II (A) Signup and view all the answers

What characterizes Phase III of the Korotkoff sounds?

Loud sounds as the blood flows freely through the open artery (D) Signup and view all the answers

What distinguishes Phase IV of the Korotkoff sounds?

Abrupt muffled sounds with a soft blowing sound (B) Signup and view all the answers

Which phase of Korotkoff sounds represents the last sound before continuous silence and is used to define diastolic pressure?

Phase V (D) Signup and view all the answers

When does the muffled or swishing sound that may disappear for up to 40mmHg long then reappear occur?

During Phase II of Korotkoff sounds (D) Signup and view all the answers

What does the abrupt muffled sound with a soft blowing sound in Phase IV indicate?

Diastolic pressure (D) Signup and view all the answers

What are the Korotkoff sounds in Phase III primarily caused by?

Blood flowing freely through an open artery (C) Signup and view all the answers

What is the primary symptom associated with orthostatic hypotension?

Pallor (A) Signup and view all the answers

What is the main cause of orthostatic hypotension?

Dehydration (D) Signup and view all the answers

What is the recommended nursing intervention for a patient with orthostatic hypotension?

Teaching and helping patient to arise and move slowly (C) Signup and view all the answers

How is orthostatic hypotension assessed?

By measuring and recording blood pressure and pulse in different positions (C) Signup and view all the answers

What is the significance of a decrease in SBP of > 20 mmHg or a decrease in DBP of > 10 mmHg within 3 minutes of standing?

It indicates orthostatic hypotension (C) Signup and view all the answers

What can be a potential cause of orthostatic hypotension?

Certain classes of medications (D) Signup and view all the answers

What factors should a nurse consider when choosing the site for temperature assessment?

The patient's state of consciousness and amount of pain (D) Signup and view all the answers

What is a characteristic of the Temporal Artery thermometer?

It measures body temperature by capturing heat emitted by the skin over the temporal muscle (B) Signup and view all the answers

What should a nurse do before taking an oral temperature if a client has been taking hot or cold foods or liquids, or smoking or chewing gum?

Wait for 30-45 minutes before taking the temperature (B) Signup and view all the answers

What is the purpose of the Disposable single-use thermometer?

To provide a non-breakable temperature measurement within seconds (B) Signup and view all the answers

What is essential for assessing temperature through the oral route?

The probe must remain in the sublingual pocket for the full period of measurement (C) Signup and view all the answers

What is an important consideration when assessing temperature through the tympanic membrane?

The presence of earwax or foreign objects in the ear canal (A) Signup and view all the answers

Which factors may decrease Basal Metabolic Rate (BMR)?

Following a very low-calorie diet and prolonged fasting (D) Signup and view all the answers

What is the main purpose of Body Mass Index (BMI)?

To provide an estimation of relative risk for heart disease, diabetes, and hypertension (C) Signup and view all the answers

What does a high BMI value indicate?

Overweight or obesity (B) Signup and view all the answers

When is Waist circumference used as a measure?

As an initial assessment of nutritional status for adults and children (B) Signup and view all the answers

What is the significance of Ideal Body Weight (IBW)?

It is an estimate of optimal body weight for optimal health (D) Signup and view all the answers

How are Height and weight tables commonly used?

To define optimal body weight for infants and children (D) Signup and view all the answers

What do higher Basal Metabolic Rates (BMRs) in men result from?

Larger muscle mass compared to women (D) Signup and view all the answers

What is the purpose of Body Mass Index (BMI) chart?

To determine the ideal body weight for adults and children (D) Signup and view all the answers

Temporal artery thermometer

A thermometer that measures temperature by detecting heat emitted from the temporal artery.

Accuracy of temporal artery thermometer

Influenced by proper technique and device cleanliness.