42 Questions
What is the primary reason for using axillary and inguinal folds as sites for temperature measurement?
They are the only safe sites for certain patients, such as CVAs.
What is the name of the sounds heard during blood pressure measurement using a stethoscope?
Korotkoff's phases
What is the term for a body temperature above normal?
Febrile
What is the correct sequence of Korotkoff's sounds during blood pressure measurement?
I, II, III, IV, V
What is the term for a body temperature below normal?
Hypothermic
Which of the following is a type of thermometer that uses an infrared scanner to measure temperature?
Infrared thermometer
What is the purpose of taking vital signs at rest?
To establish a baseline for comparison after initiation of activity
What is the phase of Korotkoff's sounds that corresponds to the diastolic blood pressure?
Phase V
What is pulse rate an indirect measure of?
Contraction of the left ventricle of the heart
What is the term for the absence of fever?
Afebrile
What is the normal range of pulse rate for neonates?
100-130 bpm
How does age affect pulse rate?
Pulse rate decreases with age
What is the effect of environmental temperature on pulse rate?
It increases pulse rate
How does physical exercise affect pulse rate?
It increases pulse rate
What happens to pulse rate after cessation of exercise?
It reverts to resting level within 3-5 minutes
What is the unit of measurement for pulse rate?
Beats per minute
What is the effect of high stress, anxiety, or emotion on pulse rate?
It increases
Where is the femoral pulse located?
Below the inguinal ligament and about midway between symphysis pubis and anterior superior iliac spine
What is the normal respiratory rate for infants?
30-50 breaths per minute
What is the term for a temperature above 106°F (41.1°C)?
Hyperpyrexia
What is the most accurate site for measuring body temperature?
Rectum
What is the term for the number of breaths per minute?
Respiratory rate
What is the effect of physical conditioning on pulse rate?
It decreases
What is the term for a temperature above 100°F (38°C)?
Pyrexia
Where is the popliteal pulse located?
In the midline of the posterior knee crease between the tendons of the hamstring muscles
What is the normal range for oral core temperature?
96.8°F to 99.3°F (36°C to 37.3°C)
What is the normal range of SBP for a 4-year-old child?
100-108 mmHg
What is the correct width of the bladder of the cuff in relation to the circumference of the midpoint of the limb?
40% of the circumference
What would be an abnormal response to exercise in terms of blood pressure?
An increase in SBP of more than 10-15 mmHg during exercise
What is the most common site used for measuring blood pressure?
Brachial artery
What is the expected response of blood pressure to emotional stress?
An increase in SBP and DBP
What would be the consequence of using a cuff that is too narrow for the patient's arm?
Erroneously high BP reading
What is the definition of hypotension in terms of blood pressure?
SBP < 90 mmHg, DBP < 60 mmHg
What is the standard arm position for measuring blood pressure?
Forearm at the level of the heart with the elbow extended
What should a patient avoid doing 30 minutes before measuring blood pressure?
Engaging in vigorous physical activity
What is considered the primary source of information when assessing pain?
Patient's self-report
What should be reassessed several times a day when managing pain?
Pain severity
What is a characteristic of chronic muscular strain?
Dull, aching pain aggravated by muscle contraction
What type of pain is characterized by a sharp, burning, or numbing sensation?
Nerve pain
What is a goal of pain management?
Eliminate source of pain when feasible
What should be documented when assessing pain?
The location, onset, and temporal pattern of pain
What type of pain is characterized by pain increasing as the day progresses?
Increased congestion in a joint
Study Notes
Vital Signs
- Vital signs are important indicators of a patient's overall health status
- Five vital signs: pulse rate, respiratory rate, blood pressure, body temperature, and pain
Pulse Rate (PR)
- Indirect measure of the contraction of the left ventricle of the heart
- Indicates heart rate (HR)
- Unit of measurement: beats per minute (bpm)
- Normal range of resting values:
- Adult: 60-100 bpm
- Neonate: 100-130 bpm
- Child 1-7 years: 80-120 bpm
- Factors affecting PR:
- Age
- Gender
- Environmental temperature
- Infection
- Physical exercise
- Emotional status
- Medications
- Cardiopulmonary disease
- Physical conditioning
- Palpation sites:
- Temporal pulse
- Carotid pulse
- Radial pulse
- Brachial pulse
- Femoral pulse
- Dorsalis pedis pulse
- Popliteal pulse
- Posterior tibial pulse
- Descriptive terms:
- Strong and regular
- Weak and regular
- Irregular
- Thready
- Tachycardic
- Bradycardic
Respiratory Rate (RR)
- One respiration comprises one inhalation and one exhalation
- Accepted normal ranges:
- Adults: 12-18 breaths per minute
- Infants: 30-50 breaths per minute
- Resting values above 20 or below 10 breaths per minute are usually considered abnormal for adults
- Factors affecting RR:
- Age
- Physical activity
- Emotional status
- Air quality
- Altitude
- Disease
Body Temperature
- Indication of the intensity or degree of heat within the body
- Under normal conditions, this remains relatively constant (thermoregulation)
- Exceptions:
- Exposure to extremes of heat or cold
- During and immediately after physical exertion
- Normal range for oral core temperature:
- 96.8°F to 99.3°F (36°C to 37.3°C)
- Average normal: 98.6°F (37°C)
- Normal range for rectal temperature:
- 97.8°F to 100.3°F (36.6°C to 38.1°C)
- Factors affecting body temperature:
- Time of day
- Gender
- Menstrual cycle
- Age
- Environmental temperature
- Infection
- Emotional status
- Site of measurement
- Physical activity
- Sites of measurement:
- Oral cavity
- Rectum (most accurate)
- Ear canal
- Axilla
- Inguinal fold
Blood Pressure (BP)
- Indirect measurement of the pressure inside an artery caused by blood flow through the artery
- Composed of systolic (SBP) and diastolic pressures (DBP)
- Measured using Korotkoff's sounds heard with a stethoscope
- Phases of Korotkoff's sounds:
- I. First faint clear tapping sounds
- II. Sounds heard have a murmur or "swishing" quality
- III. Sounds become crisp and louder
- IV. Sounds become muffled
- V. Sounds disappear
- BP norms:
- SBP < 120mmHg
- DBP < 80mmHg
- Descriptive terms:
- Pre-hypertension: SBP = 120-139mmHg; DBP = 80-89 mmHg
- Hypertension: SBP >140mmHg, DBP >90mmHg
- Hypotension: SBP < 90mmHg, DBP < 60mmHg
- Factors affecting BP:
- Age
- Exercise
- Emotional stress
- Medications
- Size and condition of arteries
- Muscle contraction
- Blood volume
- Cardiac output
- Site of measurement
Pain
- Considered the 5th vital sign
- Patient's self-report of the severity and location of pain should be the primary source of information
- Assessment should include:
- Detailed patient history
- Characteristics (e.g., intermittent, continuous, cramping, burning, dull) and intensity of pain
- Physical examination
- Psychosocial assessment
- Diagnostic evaluation of signs and symptoms associated with the cause of pain
- Goals of pain management:
- Eliminate source of pain when feasible
- Teach function within pain limitations
- Improve pain control through physical and psychological methods
- Relieve drug dependency
- Treat any underlying depression and improve mental well-being
- Address areas of secondary gain
- Pain assessment:
- Must document location, onset, and temporal pattern of pain
- Determine whether the pain radiates or is referred
- Ask patient to describe type of pain
- When is the pain least or worst
- What factors aggravate and/or relieve
- What work/social activity is affected by pain
This quiz assesses your understanding of vital signs, physical activity, and environmental factors that affect health. It covers the importance of taking vital signs at rest, establishing a baseline, and determining abnormal values.
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