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ATI VITAL SIGNS 2023
antipyretic - correct answer a substance or procedure that reduces fever apnea - correct answer temporary or transient cessation of breathing auscultatory gap - correct answer temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and is gradually reduced, with the sounds again heard at a lower level of pressure (usually occurring in patients who have hypertension) axillary - correct answer pertaining to the axilla, the cavity beneath the junction of a forelimb and the body; also called the armpit or the underarm brachial pulse - correct answer beating or throbbing felt over the brachial artery, usually palpated in the antecubital space bradycardia - correct answer an abnormally slow pulse rate, usually fewer than 60 beats per minutes in an adult bradypnea - correct answer an abnormally slow respiratory rate, usually fewer than 12 breaths per minutes in an adult cardiac output - correct answer the amount of blood pumped into the arteries by the heart during one minute; the product of the heart rate and the stroke volume Celsius - correct answer relating to the international thermometric scale on which 0° is the freezing point and 100° is the boiling point; centigrade centigrade - correct answer relating to the international thermometric scale on which 0° is the freezing point and 100° is the boiling point; Celsius core temperature - correct answer the amount of heat in the deep tissues and structures of the body, such as the liver
diastolic pressure - correct answer the force exerted when the heart is at rest in between each beat; the lowest pressure exerted against the arterial walls at all times dyspnea - correct answer the sensation of difficult or labored breathing eupnea - correct answer normal respiration febrile - correct answer feverish; pertaining to a fever fever - correct answer an elevated body temperature Korotkoff sounds - correct answer a series of five sounds (four sounds followed by an absence of sound) heard during the auscultatory determination of blood pressure and produced by sudden distention of the artery because of the proximally placed pneumatic cuff orthopnea - correct answer ability to breathe without difficulty only when in an upright position (sitting upright or standing) orthostatic hypotension - correct answer a sudden drop in blood pressure resulting from a change in position, usually when standing up from a sitting or reclining position and often causing dizziness oximetry - correct answer determination of the oxygen saturation of arterial blood using a photoelectric device called an oximeter oxygen saturation - correct answer a clinical measurement of the percentage of hemoglobin that is bound with oxygen in the blood palpation - correct answer the application of the fingers with light pressure to the surface of the body to determine the condition of the underlying parts
tympanic - correct answer pertaining to the ear canal or eardrum (tympanic membrane) vital signs - correct answer measurements of physiological functioning, specifically temperature, pulse, respirations, and blood pressure, but may also include pain and pulse oximetry The primary reason for assessing this patient's vital signs is to: - correct answer establish a baseline when the patient reports no specific health-related problem. (Vital signs are assessed for various reasons that include determining the patient's response to medical and nursing therapy as well as identifying clinical problems. However, the primary reason for such assessment at an initial visit of an apparently well patient is to document baseline data. This information will be useful for comparison with vital-sign data obtained at subsequent visits.) What can accurately describes body temperature? - correct answer The difference between heat produced by and lost from the body (Normal body temperature is the healthy balance between the amounts of heat the body produces as a byproduct of metabolism, muscle activity, thyroxine output, and sympathetic stimulation and the heat lost as a result of radiation, conduction, convection, and evaporation.) Which of the following temperatures is within the normal range for adults and is documented correctly? A. 98.6 F B. 99.6 F (O) C. 101.0 F (O) - correct answer B. 98.6 F (O) (Normal temperatures range from 96.8° F to 100.4° F. Appropriate documentation of temperature (T) includes degrees, scale (F), and assessment site: oral (O), tympanic (T), axillary (A), or rectal (R).) Which of the following is true regarding assessing a patient's pulse?
A. The human pulse is the palpable bounding of the blood flow in a peripheral artery B. The normal pulse range for a resting adult is 50 to 110 beats/min. C. Three components that the nurse should include when documenting pulse (P) are the rate, rhythm, and depth. D. To calculate the pulse of a patient whose rhythm is irregular, the nurse should count the pulse rate for 30 seconds and multiply by two. - correct answer A. The human pulse is the palpable bounding of the blood flow in a peripheral artery Will your assessment of respiration provide information about your patient's ability to intake carbon dioxide and to expel oxygen? (Yes or No) - correct answer No. Respiration is the mechanism a person uses to introduce oxygen into the body while expelling carbon dioxide into the atmosphere. Which of the following is true regarding assessing a patient's respiration? A. It is best to inform the patient that you are assessing her respiration. B. "R = 14/min, normal, regular" is an appropriate documentation of a patient's respiration. C. Occurrence or periods of apnea in an older adult is a normal respiratory finding. D. Anxiety and acute pain are two factors that should not affect a patient's respiratory rate. - correct answer B. "R = 14/min, normal, regular" is an appropriate documentation of a patient's respiration. Which of the following describes systolic pressure? A. The force blood exerts on the wall of a blood vessel during both the contraction and relaxation phases of the heart B. The pressure exerted by the blood during the heart's contraction phase C. The pressure exerted by the blood during the heart's relaxation phase - correct answer B. The pressure exerted by the blood during the heart's contraction phase You recorded your patient's blood pressure as 166/88. Is this within the normal range for an adult? (Yes or No) - correct answer No. While 120/80 mm Hg is considered a normal blood pressure for an adult, older adults may experience a rise as a result of decreased
B. for 20 seconds then multiply by 3 C. for 30 seconds then multiply by 2 - correct answer C. for 30 seconds then multiply by 2 Selecting a BP cuff that is too small for the patient's arm will result in A. a falsely high reading B. a falsely low reading - correct answer A. a falsely high reading Positioning and supporting the patient's arm at heart level is important because: A. an unsupported arm can cause a falsely high reading. B. an arm positioned below heart level can cause a falsely high reading. C. an arm positioned above heart level can cause a falsely low reading. D. it ensures a good blood flow conducive to an accurate reading. - correct answer A and C When listening to Korotkoff sounds, you would use your stethoscope's: A. bell B. diaphragm - correct answer Both A and B You inflate the cuff to 30 mm Hg higher than the patient's last recorded BP (taken at her last appointment). You note the point on the manometer where: A. you first hear Korotkoff sounds. B. the swishing sounds begin C. you hear the loudest sounds. D. the sounds become muffled E. the sound disappears - correct answer A and E
Items to include when documenting temperature - correct answer -The temperature reading -The route you used to measure the temperature -Any signs or symptoms of temperature alterations -Your nursing interventions ("antipyretic given") -The patient's response to care Items to include when documenting pulse - correct answer -The rate, rhythm, and strength of the pulse -The site you used to palpate the pulse -Any signs or symptoms of pulse alterations -The pulse deficit (if applicable) -Your nursing interventions -The patient's response to care Items to include when documenting respirations - correct answer -The rate, rhythm, and depth of respirations -Any signs or symptoms of respiratory alterations -Abnormal respiratory sounds -The type of oxygen therapy (nasal cannula, mask) and flow rate -Respiratory status after a specific treatment (nebulizer therapy) -Any specimens and cultures obtained and sent to the lab -Your nursing interventions -The patient's response to care Items to include when documenting blood pressure - correct answer -The blood pressure reading -The site where you measured the blood pressure -Any signs or symptoms of blood-pressure alterations -Your nursing interventions -The patient's response to care
