Beruflich Dokumente
Kultur Dokumente
1a
1b
Blood pressure is reflected by the following. Briefly explain each. Blood volume
2a
The volume of blood circulating within the vascular system affects blood pressure, which normally remains constant
2b
Blood pressure is reflected by the following. Briefly explain each. Cardiac output
3a
Cardiac output increases as a result of an increase in heart rate, greater heart muscle contractility, or an increase in blood volume
3b
4a
With reduced elasticity, there is greater resistance to blood flow, and the systemic pressure rises (systolic pressure)
4b
Blood pressure is reflected by the following. Briefly explain each. Peripheral resistance
5a
Peripheral resistance is the resistance to blood flow determined by the tone of vascular musculature and diameter of blood vessels
5b
6a
Viscosity is the thickness that affects the ease with which blood flows through blood vessels, determined by the hematocrit
6b
7a
7b
8a
Biot respirations are abnormally shallow for two to three breaths followed by irregular period of apnea
8b
9a
9b
10a
Respiratory rate and depth are irregular; alternating periods of apnea and hyperventilation
10b
11a
Respirations are labored and increased in depth, and the rate is >20 breaths/min
11b
12a
12b
13a
13b
14a
14b
15a
Sa02 is the percentage of hemoglobin that is bound with oxygen in the arteries is the percent of saturation of hemoglobin; normal range is usually between 95% and 100%
15b
16a
16b
17a
17b
18a
18b
19a
19b
20a
20b
Conduction
21a
21b
Convection
22a
22b
Core temperature
23a
23b
24a
In some patients with hypertension, the sounds usually heard over the brachial artery when the cuff pressure is high disappear as pressure is reduced and the reappear at a lower level. This temporary disappearance of sound is the auscultatory gap,
24b
25a
25b
26a
26b
27a
Pulse deficit is an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral site; it is the difference between the apical and he radial pulse rate
27b
28a
28b
29a
Diffusion is the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
29b
30a
30b
31a
Perfusion is the distribution of red blood cells to and from the pulmonary capillaries
31b
32a
32b
33a
Blood pressure is the force exerted on the walls of an artery by the pulsing blood under pressure from the heart
33b
34a
Diastolic pressure occurs when the ventricles relax; the blood remaining in the arteries exerts a minimum pressure
34b
35a
35b
36a
36b
Evaporation
37a
37b
Explain the differences related to febrile states in each of the following. Children
38a
Children have immature temperaturecontrol mechanisms, so their temperatures can rise rapidly, and they are at risk for fluid-volume deficit
38b
Explain the differences related to febrile states in each of the following. Hypersensitive response to drugs
39a
Drug fevers are often accompanied by other allergy symptoms such as rash or pruritus
39b
40a
Move the patient to a cooler environment; remove excess body clothing; place cool, wet towels over the skin; and use fans
40b
Frostbite
41a
41b
42a
Nonpharmacologic therapy includes tepid sponge baths, bathing with alcohol water solutions, applying ice packs to the axillae and groin sites, and cooling fans
42b
43a
43b
Heat exhaustion
44a
44b
Heatstroke
45a
45b
Hyperthermia
46a
46b
Hypothalamus
47a
47b
Hypothermia
48a
48b
Identify at least one teaching consideration that emphasizes health promotion for the following vital signs. Blood pressure
49a
Instruct patients on normal blood pressure values, risk factors for hypertension, usual lack of hypertension symptoms, ability of therapy to control but not cure, and benefits of a consistently followed hypertension treatment plan. Demonstrate how to obtain blood pressure to the patient's family caregiver using an appropriate-size blood pressure cuff for home use at the same time each day, after patient has had a brief rest, and the same position and arm each time pressure is taken.
49b
Identify at least one teaching consideration that emphasizes health promotion for the following vital signs. Pulse
50a
Instruct patients on risk factors for hypothermia, frostbite, and heat stroke. Demonstrate selfassessment of heart rate using the carotid pulse. Patients taking certain prescribed cardiac medications need to learn to assess their own pulse rate to detect side effects of medications. Patients undergoing cardiac rehabilitation need to learn to assess their own pulse rate to determine their response to exercise.
50b
Identify at least one teaching consideration that emphasizes health promotion for the following vital signs. Respirations
51a
Instruct patient on signs and symptoms of hypoxemia. Instruct patient on the effect of cigarette smoking on oxygen saturation.
51b
Identify at least one teaching consideration that emphasizes health promotion for the following vital signs. Temperature
52a
52b
Identify at least two variations that are unique to older adults. Blood pressure
53a
a. Older adults often have decreased upper arm mass, which requires special attention to selection of blood pressure cuff size. b. Older adults sometimes have an increase in systolic pressure related to decreased vessel elasticity while the diastolic pressure remains the same, resulting in a wider pulse pressure. c. Instruct older adults to change position slowly and wait after each change to avoid postural hypotension and prevent injuries.
53b
Identify at least two variations that are unique to older adults. Pulse
54a
a. If it is difficult to palpate the pulse of an obese older adult, a Doppler device provides a more accurate reading. b. The older adult has a decreased heart rate at rest. c. It takes longer for the heart rate to rise in the older adult to meet sudden increased demands that result from stress, illness, or excitement. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate. d. When assessing the apical rate of an older woman, the breast tissue is gently lifted, and the stethoscope placed at the fifth intercostal space (ICS) or the lower edge of the breast. e. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs.
54b
Identify at least two variations that are unique to older adults. Respirations
55a
a. Aging causes ossification of costal cartilage and downward slant of ribs, resulting in a more rigid rib cage, which reduces chest wall expansion. Kyphosis and scoliosis that occur in older adults also restrict chest expansion and decrease tidal volume. b. Older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles. c. The respiratory system matures by the time a person reaches 20 years of age and begins to decline in healthy people after the age of 25. Despite this decline older adults are able to breathe effortlessly as long as they are healthy. However, sudden events that require an increased demand for oxygen (e.g., exercise, stress, illness) create shortness of breath in the older adult. d. Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia. 55b
Identify at least two variations that are unique to older adults. Temperature
56a
a. The temperature of older adults is at the lower end of the normal temperature range, 36 to 36.8 C (96.8 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99 F) rectally. Therefore temperatures considered within normal range sometimes reflect a fever in an older adult. In an older adult fever is present when a single oral temperature is over 37.8 C (100 F); repeated oral temperatures are over 37.2 C (99 F); rectal temperatures are over 37.5 C (99.5 F); or temperature has increased more than 1 C (2 F) over baseline b. Older adults are very sensitive to slight changes in environmental temperature because their thermoregulatory systems are not as efficient. c. A decrease in sweat gland reactivity in the older adult results in a higher threshold for sweating at high temperatures, which leads to hyperthermia and heatstroke. d. Be especially attentive to subtle temperature changes and other manifestations of fever in this population such as tachypnea, anorexia, falls, delirium, and overall functional decline. e. With aging loss of subcutaneous fat reduces the insulating capacity of the skin; older men are especially high risk for hypothermia.
56b
57a
Body temperature will return to an acceptable range, other vital signs will stabilize, and the patient will report a sense of comfort
57b
Identify factors that influence the character of respirations and the mechanism of each factor (8)
58a
a. Exercise - exercise increases rate and depth to meet the body's need for additional oxygen and to rid the body of CO2 b. Acute Pain - pain alters rate and rhythm of respirations; breathing becomes shallow ; Patient inhibits or splint chest wall movement when pain is in area of chest or abdomen c. Anxiety - anxiety increases respiration rate and depth as a result of sympathetic stimulation d. Smoking - chronic smoking changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking e. Body Position - A straight, erect posture promotes full chest expansion; A stooped or slumped position impairs ventilatory movement; Lying flat prevents full chest expansion f. Medications - opioid analgesics, general anesthetics, and sedative hypnotics depress rate and depth; amphetamines and cocaine sometimes increase rate and depth; bronchodilators slow rate by causing airway dilation g. Neurological Injury - injury to brainstem impairs respirator center and inhibits respiratory rate and rhythm h. Hemoglobin Function - decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate; increased altitude lowers amount of saturated hemoglobin, which increases respiratory rate and depth; abnormal blood cell function (e.g., sickle cell disease) reduces ability of hemoglobin to cary oxygen, which increases respiratory rate and depth.
58b
59a
59b
Identify seven factors that may increase or decrease the pulse rate. (7)
60a
61a
Dehydrated, anemic, experienced prolonged bed rest, recent blood loss, medications
61b
Identify the acceptable range for respiratory rates for the following age groups. Adolescents
62a
16 to 20
62b
Identify the acceptable range for respiratory rates for the following age groups. Adults
63a
12 to 20
63b
Identify the acceptable range for respiratory rates for the following age groups. Children
64a
20 to 30
64b
Identify the acceptable range for respiratory rates for the following age groups. Infants
65a
30 to 50
65b
Identify the acceptable range for respiratory rates for the following age groups. Newborns
66a
35 to 40
66b
Identify the acceptable range for respiratory rates for the following age groups. Toddlers
67a
25 to 32
67b
68a
a. Age b. Exercise c. Hormone level d. Circadian rhythm e. Stress f. Environment g. Temperature alterations (fever, hyperthermia, heat stroke, heat exhaustion, hypothermia)
68b
69a
69b
70a
Clear rhythmic tapping corresponding to the pulse rate that gradually increases in intensity (systolic pressure)
70b
71a
Muffled and low-pitched as the cuff further deflated (diastolic pressure in infants and children)
71b
72a
72b
73a
73b
Identify the guidelines that assist the nurse with incorporating vital sign measurement into practice. (12)
74a
a. The nurse may delegate the measurement of vital signs but is responsible for analyzing and interpreting their significance and select appropriate interventions b. Equipment needs to be appropriate and functional c. Equipment needs to be based on the patient's condition and characteristics d. Know the patient's usual range of vital signs e. Know the patient's medical history f. Control or minimize environmental factors g. Use a systematic approach h. Collaborate with health care providers to decide on the frequency i. Use measurements to determine the indications for medication administration j. Analyze the results k. Verify and communicate significant changes with the patient's health care provider l. Develop a teaching plan
74b
Identify the measurement criteria for the following pulse sites. Apical
75a
75b
Identify the measurement criteria for the following pulse sites. Brachial
76a
76b
Identify the measurement criteria for the following pulse sites. Carotid
77a
77b
Identify the measurement criteria for the following pulse sites. Dorsalis pedis
78a
Along top of foot, between extension tendons of great and first toe
78b
Identify the measurement criteria for the following pulse sites. Femoral
79a
Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine
79b
Identify the measurement criteria for the following pulse sites. Popliteal
80a
80b
Identify the measurement criteria for the following pulse sites. Posterior tibial
81a
81b
Identify the measurement criteria for the following pulse sites. Radial
82a
82b
Identify the measurement criteria for the following pulse sites. Temporal
83a
83b
Identify the measurement criteria for the following pulse sites. Ulnar
84a
84b
Identify the optimal blood pressure for the following ages. 1 month
85a
85/54 mm Hg
85b
Identify the optimal blood pressure for the following ages. 1 year
86a
95/65 mm Hg
86b
Identify the optimal blood pressure for the following ages. 6 years
87a
105/65 mm Hg
87b
Identify the optimal blood pressure for the following ages. 10 to 13 years
88a
110/65 mm Hg
88b
Identify the optimal blood pressure for the following ages. 14 to 17 years
89a
119/75 mm Hg
89b
Identify the optimal blood pressure for the following ages. Newborn
90a
40 (mean) mm Hg
90b
Identify the optimal blood pressure for the following ages. Older than 18 years
91a
<120/80 mm Hg
91b
92a
Those at risk include the very young and very old; persons debilitated by trauma, stroke, or diabetes; those who are intoxicated by drugs or alcohol; patients with sepsis; and those who have inadequate home heating and shelter. Fatigue, dark skin color, malnutrition; and hypoxemia also increase the risk
92b
Identify the two common sites to assess the pulse rate, (2)
93a
a. Radial b. Apical
93b
94a
Passive
94b
95a
Active
95b
List at least one advantage and one disadvantage of each of the following temperature sites. Axilla
96a
A~ a. Safe and inexpensive b. Used with newborns and unconscious patients D~ a. Long measurement time b. Underestimates core temperature c. Requires continuous positioning by nurse d. Measurement lags behind core temperature during rapid temperature changes e. Not recommended to detect fever in infants and young children f. Requires exposure of thorax, which results in temperature loss, especially in newborns g. Affected by exposure to environment, including time to place thermometer 96b
List at least one advantage and one disadvantage of each of the following temperature sites. Oral
97a
A~ a. Easily accessible - requires no position change b. Comfortable for patient c. Provides accurate surface temperature reading d. Reflects rapid change in core temperature e. Reliable route to measure temperature in patients who are intubated D~ a. Causes delay in measurement if patient recently ingested hot/cold fluids or foods, smoked, or is receiving oxygen by mask/cannula b. Not for patients who had oral surgery, trauma, history of epilepsy, or shaking chills c. Not for infants, small children, or patients who are confused, unconscious, or uncooperative d. Risk of body fluid exposure 97b
List at least one advantage and one disadvantage of each of the following temperature sites. Rectal
98a
A~ a. Sometimes considered to be more reliable when oral temperature cannot be obtained D~ a. Lags behind core temperature during rapid temperature changes b. Not for patients with diarrhea, rectal disorders, or bleeding tendencies or those who had rectal surgery c. Requires positioning and is often source of patient embarrassment and anxiety d. Risk of body fluid exposure e. Requires lubrication f. Not for routine vital signs in newborns g. Readings influenced by impacted stool
98b
List at least one advantage and one disadvantage of each of the following temperature sites. Skin
99a
A~ a. Inexpensive b. Provides continuous reading c. Safe and noninvasive d. Used for neonates D~ a. Measurement lags behind other sites during temperature changes, especially during hyperthermia b. Adhesion impaired by diaphoresis or sweat c. Reading affected by environmental temperature d. Cannot ne used for patients with allergy to adhesive
99b
List at least one advantage and one disadvantage of each of the following temperature sites. Temporal artery
100a
A~ a. Easy to access without position change b. Very rapid measurement c. No risk of injury to patient or nurse d. Eliminates need to disrobe or be unbundled e. Comfortable for patient f. Used in premature infants, newborns, and children g. Reflects rapid change in core temperature h. Sensor cover not required D~ a. Inaccurate with head covering or hair on forehead b. Affected by skin moisture such as diaphoresis or sweating
100b
List at least one advantage and one disadvantage of each of the following temperature sites. Tympanic
101a
A~ a. Easily accessible site b. Minimal patient repositioning required c. Obtained without disturbing, waking, or repositioning patients d. Used for patients with tachypnea without affecting breathing e. Provides accurate core reading because eardrum close to hypothalamus; sensitive to core temperature changes f. Very rapid measurement (2 to 5 seconds) g. Unaffected by oral intake of food or fluids or smoking h. Used in newborns to reduce infant handling and heat loss D~ a. More variability of measurement than with other core temperature devices b. Requires removal of hearing aids before measurement c. Requires disposable sensor cover with only one size available d. Otitis media and cerumen impaction distorts readings e. Not used in patients who have had surgery of the ear or tympanic membrane f. Does not accurately measure core temperature changed during and after exercise g. Does not obtain continuous measurement h. Affected by ambient temperature devices such as incubators, radiant warmers, and facial fans i. When used in neonates, infants, and children under 3 years old, use care to position device correctly because anatomy of ear canal makes it difficult to position j. Inaccuracies reported caused by incorrect positioning of handheld unit
101b
102a
a. Age b. Stress c. Ethnicity d. Gender e. Daily variations f. Medications g. Activity and weight h. Smoking
102b
103a
Family history, obesity, cigarette smoking, heavy alcohol consumption, high sodium, sedentary lifestyle, exposure to continuous stress, diabetics, older African Americans
103b
104a
60 to 90
104b
105a
60 to 100
105b
106a
120 to 160
106b
107a
80 to 110
107b
List the acceptable pulse ranges for the following. School-age children
108a
75 to 100
108b
109a
90 to 140
109b
List the characteristics to identify when assessing the following. Apical pulse
110a
When assessing the apical pulse, consider rate and rhythm only
110b
List the characteristics to identify when assessing the following. Radial pulse
111a
When assessing the radial pulse, consider rate, rhythm, strength, and equality
111b
Malignant hyperthermia
112a
112b
Nonshivering thermogenesis
113a
113b
Provide examples of goals for temperature alterations related to the environment. Long term
114a
114b
Provide examples of goals for temperature alterations related to the environment. Short term
115a
115b
Pyrexia
116a
Fever
116b
Pyrogens
117a
117b
Radiation
118a
Transfer of heat from the surface of one object to the surface of another with our direct contact
118b
Shivering
119a
119b
120a
120b
121a
Subtract 32 from the Fahrenheit reading and multiple the result by 5/9
121b
122a
122b
123a
a. The degree of temperature extreme b. The person's ability to sense feeling comfortable c. Thought processes or emotions d. Person's mobility or ability to remove or add clothes
123b
The nurse bathes the patient who has a fever with cool water. The nurse does this to increase heat loss by means of: 1. Radiation 2. Convection 3. Conduction 4. Condensation
124a
3. The transfer of heat from one object to an other without direct contact (solids, liquids, and gases)
124b
The nurse is assessing a patient who she suspects has the nursing diagnosis hypothermia related to vigorous exercise in hot weather. In reviewing the data, the nurse knows that the most important sign of heatstroke is: 1. Confusion 2. Excess thirst 3. Hot, dry skin 4. Muscle cramps
125a
125b
The nurse is auscultating Mrs. McKinnon's blood pressure. The nurse inflates the cuff to 180mm Hg. At 156mm HG, the nurse hears the onset of a tapping sound. At 130mm Hg, the sound changes to a murmur or swishing. At 100mm Hg, the sound momentarily becomes sharper, and at 92mm Hg, it becomes muffled. At 88mm Hg, the sound disappears. Mrs. McKinnon's blood pressure is: 1. 130/88mm Hg 2. 156/88mm Hg 3. 180/92mm Hg 4. 180/130mm Hg
126a
2. 156 is the onset of the first Korotkoff sound (systolic pressure), and 88 is the fifth sound that corresponds with the diastolic pressure
126b
The skin plays a role in temperature regulation by: 1. Insulating the body 2. Constricting blood vessels 3. Sensing external temperature variations 4. All of the above
127a
4. The skin regulates temperature through insulation of the body, vasoconstriction, and temperature sensations.
127b
Thermoregulation
128a
Mechanisms that regulate the balance between heat lost and heat produced
128b