34 Questions
What is an advantage of oral temperature measurement?
Accessible
Which pulse site is commonly called the arterial or peripheral pulse?
Dorsalis pedis
What is a disadvantage of tympanic temperature measurement?
Membrane Injury
Where is the common arterial or peripheral pulse site located?
Over the bones of the foot
What is a characteristic of a normal pulse rate for adults?
Between 60 and 100 beats per minute
Which pulse site is used to determine the circulation to the foot when the radial pulse is not accessible?
Temporal
What is the range for rectal temperature according to the text?
Between 36.3OC - 37.9OC
What is the purpose of assessing the general survey of a client's health status?
To establish baseline data for subsequent evaluation
Which hormone is responsible for the regulation of metabolism (BMR)?
Thyroxine (T4)
What is the purpose of a thermoneutral environment according to the text?
To keep cool without affecting basal metabolic rate
What process allows the body to maintain its core temperature?
Thermoregulation
Which factor can influence body temperature due to its effect on metabolic rate?
Stress
What is the approximate range for axillary temperature as per the text?
Between 35.4OC - 37.0OC
What can be a probable cause of Pyrexia or Fever based on the text?
Dehydration
What is the main role of Shivering according to the text?
Increase metabolic rate
How do large muscles contribute to heat production according to the text?
By generating heat through muscle activity
What is the first step a nurse should take when assessing a client's pulse rate?
Palpate a peripheral pulse by placing fingers on the pulse point with moderate pressure
Which artery is routinely used for infants and children up to 3 years of age during cardiac arrest/shock?
Brachial
What does a pulse deficit refer to?
Condition in which apical pulse rate is greater than radial pulse rate
What is bradycardia?
Heart rate less than 60 beats per minute in an adult
What is arterial elasticity indicative of?
Resilient and springy artery
Which artery runs along the radial bone, on the thumb side of the inner wrist?
Radial
What does pulse volume measure?
Strength or amplitude of blood force against the arterial wall
What is tachycardia characterized by?
>100 beats per minute heart rate in an adult
What is the primary muscle used in diaphragmatic breathing?
Abdominal muscles
Which term refers to the cessation of breathing?
Apnea
What does dyspnea refer to?
Difficulty of breathing
Which sound is associated with a high-pitched musical squeak on expiration?
Wheeze
What is the purpose of diaphragmatic breathing?
To achieve greater expansion and ventilation in the lower part of the lungs
Which term is used to describe overexpansion of the lungs with rapid deep breaths?
Hyperventilation
What sound is associated with a snoring or sonorous respiration?
Stetor
'Atelectasis' refers to:
Partial or complete collapse of alveoli in the lungs
Which term refers to quick, shallow breathing usually seen during tension and anxiety?
Tachypnea
What is the primary function of diffusion in respiration?
Exchange of oxygen and carbon dioxide between alveoli and blood
Study Notes
Vital Signs
Body Temperature
- Normal body temperature range: 36.3°C - 37.9°C
- Factors affecting body temperature: age, exercise, hormones, environment, and stress
- Methods of temperature measurement: oral, rectal, axillary, temporal, and tympanic
- Importance of temperature regulation: maintaining core body temperature at 37°C
Pulse
- Definition: a shock wave produced by the contraction of the heart and measured at peripheral pulse sites
- Normal pulse rate for adults: 60-100 beats per minute
- Pulse characteristics: quality, rate, rhythm, and volume
- Pulse sites: radial, ulnar, femoral, popliteal, posterior tibialis, and dorsalis pedis
- Importance of pulse measurement: indirect measurement of cardiac output
Respiration
- Definition: the act of breathing, including external respiration (gas exchange between alveoli and pulmonary blood) and internal respiration (gas exchange between circulating blood and body tissues)
- Normal breathing: slightly observable, effortless, quiet, automatic, and regular
- Types of breathing: coastal/thoracic, abdominal/diaphragmatic, and apnea (cessation of breathing)
- Importance of respiration: exchange of oxygen and carbon dioxide between the lungs and body tissues
Blood Pressure
- Definition: the measure of pressure exerted as blood flows through the artery
- Importance of blood pressure measurement: indicator of cardiovascular health
Health Assessment
General Health Status
- Importance of temperature measurement in health assessment
- Vital signs: indicators of health, including body temperature, pulse, respiration, and blood pressure
- Purpose of vital signs measurement: to determine changes in health status and monitor clients at risk for imbalance
Additional Concepts
Thermoregulation
- Definition: the process of maintaining core body temperature at 37°C
- Factors affecting heat production: basal metabolic rate, thyroxine (T4) output, and thyronine (T3) output
Thyroid Hormones
- Thyroxine (T4): a thyroid hormone regulating metabolism (BMR)
- Triiodothyronine (T3): a thyroid hormone regulating metabolism (BMR)
Fever
- Definition: an increase in body temperature above the normal range
- Causes of fever: medical conditions (viral, bacterial, parasitic infections)
- Manifestations of fever: flushed skin, sweating, increased heart rate and breathing rate, and headache
Test your knowledge on nursing assessment techniques, including how to assess normal pulse rate, palpate peripheral pulses, and count pulse rate while noting rhythm. This quiz also covers assessing for a pulse deficit and understanding the internal carotid artery.
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