Vital Signs in Nursing

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Questions and Answers

What is the normal heart rate at rest?

60-100 beats per minute (correct)

80-120 beats per minute

100-140 beats per minute

50-80 beats per minute

What is arterial pulse defined as?

A pressure wave generated by the ejection of blood into the circulation from the left ventricle (correct)

The movement of blood through the arteries

The measurement of blood flow through the veins

The contraction and relaxation of the heart

What is bradycardia defined as?

A rapid heart rate

A pulse rate of > 100 bpm

An irregular heart rhythm

A pulse rate of < 60 bpm (correct)

What is the term for a heart rate that varies with the respiratory cycle?

Sinus arrhythmia Signup and view all the answers

What is the term for an irregular heart rhythm with no appreciable pattern?

Atrial fibrillation Signup and view all the answers

Which of the following is NOT a type of pulse?

Cardiac pulse Signup and view all the answers

What is the recommended size of the bladder in a standard adult cuff for blood pressure measurement?

13×30 cm Signup and view all the answers

What is the significance of a difference of more than 10 mmHg in blood pressure between the two arms?

It suggests the presence of aortic or subclavian artery disease Signup and view all the answers

Why is it important to palpate the systolic pressure first in blood pressure measurement?

To avoid missing the first appearance of the Korotkoff sound Signup and view all the answers

What is the normal range of respiratory rate in an adult at rest?

12-20 breaths per minute Signup and view all the answers

What is the term for a respiratory rate of more than 20 breaths per minute?

Tachypnea Signup and view all the answers

What is the effect of a 7 cm change in arm elevation on blood pressure measurement?

A change of approximately 5 mmHg in recorded systolic and diastolic BP Signup and view all the answers

What condition is most likely indicated by a beat-to-beat variation in pulse volume with a normal rhythm?

Pulsus alternans Signup and view all the answers

What is the definition of hypothermia?

A core temperature of less than 37.2°C Signup and view all the answers

What condition is characterized by a gradual upstroke with a reduced peak occurring late in systole?

Severe aortic stenosis Signup and view all the answers

What is the primary diagnostic feature of pulsus bisferiens?

A double systolic peak Signup and view all the answers

Why should the respiratory rate be measured quietly and without drawing the patient's attention to it?

To avoid affecting the patient's respiratory rate Signup and view all the answers

Which condition is most likely to explain a low pulse volume?

Cardiac tamponade Signup and view all the answers

Which of the following can cause asymmetric pulses?

Atherosclerosis Signup and view all the answers

What does a blood pressure reading of 146/92 mmHg indicate?

Hypertension Signup and view all the answers

Which condition is associated with a rapid fall in pressure after the peak of the pulse wave?

Collapsing pulse Signup and view all the answers

What is pulsus paradoxus most commonly associated with?

Cardiac tamponade Signup and view all the answers

Study Notes

Vital Signs

Arterial pulse is a pressure wave generated by the ejection of blood into the circulation from the left ventricle.

Arterial Pulse

Can be measured at the radial, brachial, carotid, or femoral arteries.
Has four components:
- Rate: 60-100 beats per minute at rest.
- Rhythm: regular or irregular.
- Volume: perceived degree of pulsation.
- Character: pulse waveform impression or shape.

Abnormal Pulse Rates

Bradycardia: a pulse rate of < 60 bpm.
Tachycardia: a rate of > 100 bpm.
Sinus arrhythmia: a regular rhythm with a heart rate that varies with the respiratory cycle.
Atrial fibrillation: an irregularly irregular pulse.

Blood Pressure

Important steps to measure blood pressure:
- Use a proper cuff size (13x30 cm for a standard adult cuff).
- Record the highest pressure and use it to guide management.
- Avoid auscultatory gap by palpating the systolic pressure first.
- Ensure the patient's arm is at the appropriate level (elbow level with the heart).
Normal blood pressure values: not specified.

Respiratory Rate

Measured by quietly observing and timing the respiratory rate (e.g., breaths in 15 seconds × 4).
Normal respiratory rate: 12-20 breaths per minute at rest.
Abnormal respiratory rates:
- Tachypnea: RR > 20.
- Bradypnea: RR < 12.

Temperature

Normal temperature: 37.2°C or an afternoon temperature of < 37.7°C.
Abnormal temperatures:
- Hypothermia: a core temperature < 37.2°C.
- Fever: a temperature > 37.7°C.

Pulse Volume and Character

Pulse volume varies with pulse pressure.
Low pulse volume may be due to:
- Severe heart failure.
- Hypovolemia.
- Cardiac tamponade.
- Mitral stenosis.
- Coarctation of the aorta.
Asymmetric pulses may be due to:
- Atherosclerosis or stenosis of peripheral arteries.
- Aortic dissection.
Abnormal pulse characters:
- Slow-rising pulse: gradual upstroke with a reduced peak occurring late in systole.
- Collapsing pulse: the peak of the pulse wave arrives early and is followed by a rapid fall in pressure.
- Pulsus bisferiens: a double systolic peak.
- Pulsus alternans: beat-to-beat variation in pulse volume with a normal rhythm.
- Pulsus paradoxus: exaggeration of the normal variability of pulse volume with breathing.

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Description

A quiz on vital signs, covering normal values, examination components, and related abnormalities. Includes arterial pulse, blood pressure, respiratory rate, and temperature.