Basal metabolic rate

1a

The heat produced by the body at absolute rest

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

Blood pressure is reflected by the following. Briefly explain each. Elasticity

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

Blood pressure is reflected by the following. Briefly explain each. Viscosity

6a

Viscosity is the thickness that affects the ease with which blood flows through blood vessels, determined by the hematocrit

6b

Briefly explain the following alterations in breathing patterns. Apnea

7a

Respirations cease for several seconds

7b

Briefly explain the following alterations in breathing patterns. Biot

8a

Biot respirations are abnormally shallow for two to three breaths followed by irregular period of apnea

8b

Briefly explain the following alterations in breathing patterns. Bradypnea

9a

Rate of breathing is regular but slow; <12 breaths/min

9b

Briefly explain the following alterations in breathing patterns. Cheyne-Stokes

10a

Respiratory rate and depth are irregular; alternating periods of apnea and hyperventilation

10b

Briefly explain the following alterations in breathing patterns. Hyperpnea

11a

Respirations are labored and increased in depth, and the rate is >20 breaths/min

11b

Briefly explain the following alterations in breathing patterns. Hyperventilation

12a

Rate and depth of respirations increase

12b

Briefly explain the following alterations in breathing patterns. Hypoventilation

13a

Respiratory rate is abnormally low, and depth of ventilation is depressed

13b

Briefly explain the following alterations in breathing patterns. Kussmaul

14a

Kussmaul respirations are abnormally deep, regular and increased in rate

14b

Briefly explain the following alterations in breathing patterns. SaO2

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

Briefly explain the following alterations in breathing patterns. Tachypnea

16a

Rate of breathing is regular but rapid; >20 breaths/min

16b

Category: Normal Systolic: ? Diastolic: ?

17a

Systolic: <120 Diastolic: <80

17b

Category: Prehypertension Systolic: ? Diastolic: ?

18a

Systolic: 120-139 Diastolic: 80-89

18b

Category: Stage 1 hypertension Systolic: ? Diastolic: ?

19a

Systolic: 140-159 Diastolic: 90-99

19b

Category: Stage 2 hypertension Systolic: ? Diastolic: ?

20a

Systolic: >_160 Diastolic: >_100

20b

Conduction

21a

Transfer of heat from one object to another with direct contact

21b

Convection

22a

Transfer of heat away by air movement

22b

Core temperature

23a

Temperature of the deep tissues

23b

Define auscultatory gap

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

Define the following term. Bradycardia

25a

Bradycardia is a slow rate (<60 beats/min in adults)

25b

Define the following term. Dysrhythmia

26a

A dysrhythmia is an abnormal rhythm, including early, late or missed beats

26b

Define the following term. Pulse deficit

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

Define the following term. Tachycardia

28a

Tachycardia is an abnormal elevated heart rate (>100 beats/min in adults)

28b

Define the following terms related to respirations. Diffusion

29a

Diffusion is the movement of oxygen and carbon dioxide between the alveoli and the red blood cells

29b

Define the following terms related to respirations. Hypoxemia

30a

Hypoxemia is low levels of arterial 02

30b

Define the following terms related to respirations. Perfusion

31a

Perfusion is the distribution of red blood cells to and from the pulmonary capillaries

31b

Define the following terms related to respirations. Ventilation

32a

Ventilation is the movement of gases in and out of the lungs

32b

Define the following terms. Blood pressure

33a

Blood pressure is the force exerted on the walls of an artery by the pulsing blood under pressure from the heart

33b

Define the following terms. Diastolic pressure

34a

Diastolic pressure occurs when the ventricles relax; the blood remaining in the arteries exerts a minimum pressure

34b

Define the following terms. Pulse pressure

35a

Pulse pressure is the difference between systolic and diastolic pressure

35b

Define the following terms. Systolic pressure

36a

Systolic pressure is the peak of maximum pressure when ejection occurs

36b

Evaporation

37a

Transfer of heat energy when a liquid is changed to a gas

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

First aid treatment for heatstroke is:

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

Occurs when the body is exposed to subnormal temperatures

41b

Give an example of each type of fever therapy. Nonpharmacologic

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

Give an example of each type of fever therapy. Pharmacologic

43a

Pharmacologic therapy includes non steroidal drugs and corticosteroids

43b

Heat exhaustion

44a

Profuse diaphoreses with excess water and electrolyte loss

44b

Heatstroke

45a

A dangerous heat emergency

45b

Hyperthermia

46a

The body's inability to promote heat loss or reduce heat production

46b

Hypothalamus

47a

Controls body temperature

47b

Hypothermia

48a

Cold that overwhelms the body's ability to produce heat

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

Explain measures to prevent body temperature alterations

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

Identify evaluative measures for temperature alterations

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

Identify four nursing diagnoses related to thermoregulation. (4)

59a

a. Risk for Imbalanced Body Temperature b. Hyperthermia c. Hypothermia d. Ineffective Thermoregulation

59b

Identify seven factors that may increase or decrease the pulse rate. (7)

60a

a. Exercise b. Temperature c. Emotions d. Drugs e. Hemorrhage f. Postural changes g. Pulmonary conditions

60b

Identify some of the risk factors for orthostatic hypotension

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

Identify the factors that affect body temperature. (7)

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

Identify the following Korotkoff sounds. Fifth

69a

The disappearance of sound (diastolic pressure in adolescents and adults)

69b

Identify the following Korotkoff sounds. First

70a

Clear rhythmic tapping corresponding to the pulse rate that gradually increases in intensity (systolic pressure)

70b

Identify the following Korotkoff sounds. Fourth

71a

Muffled and low-pitched as the cuff further deflated (diastolic pressure in infants and children)

71b

Identify the following Korotkoff sounds. Second

72a

Blowing or swishing sound as the cuff deflates

72b

Identify the following Korotkoff sounds. Third

73a

A crisper and more intense tapping

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

Fourth to fifth intercostal space at left midclavicular line

75b

Identify the measurement criteria for the following pulse sites. Brachial

76a

Groove between biceps and triceps muscles at antecubital fossa

76b

Identify the measurement criteria for the following pulse sites. Carotid

77a

Along medial edge of sternocleidomastoid muscle in neck

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

Behind knee in popliteal fossa

80b

Identify the measurement criteria for the following pulse sites. Posterior tibial

81a

Inner side of ankle, below medial malleolus

81b

Identify the measurement criteria for the following pulse sites. Radial

82a

Radial or thumb side of forearm at wrist

82b

Identify the measurement criteria for the following pulse sites. Temporal

83a

Overal temporal bone of head, above and lateral to eye

83b

Identify the measurement criteria for the following pulse sites. Ulnar

84a

Ulnar side of forearm at wrist

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

Identify the patients who are at risk for hypothermia.

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

Identify which phase of respirations is active and which is passive. Expirations

94a

Passive

94b

Identify which phase of respirations is active and which is passive. Inspiration

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

List eight factors that influence blood pressure. (8)

102a

a. Age b. Stress c. Ethnicity d. Gender e. Daily variations f. Medications g. Activity and weight h. Smoking
102b

List some of the risk factors that are linked to hypertension

103a

Family history, obesity, cigarette smoking, heavy alcohol consumption, high sodium, sedentary lifestyle, exposure to continuous stress, diabetics, older African Americans

103b

List the acceptable pulse ranges for the following. Adolescents

104a

60 to 90

104b

List the acceptable pulse ranges for the following. Adults

105a

60 to 100

105b

List the acceptable pulse ranges for the following. Infants

106a

120 to 160

106b

List the acceptable pulse ranges for the following. Preschoolers

107a

80 to 110

107b

List the acceptable pulse ranges for the following. School-age children

108a

75 to 100

108b

List the acceptable pulse ranges for the following. Toddlers

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

Hereditary condition of uncontrolled heat production

112b

Nonshivering thermogenesis

113a

Vascular brown tissue is metabolized for heat production in the neonate

113b

Provide examples of goals for temperature alterations related to the environment. Long term

114a

Obtain appropriate clothing to wear in cold weather

114b

Provide examples of goals for temperature alterations related to the environment. Short term

115a

Regain normal range of body temperature

115b

Pyrexia

116a

Fever

116b

Pyrogens

117a

Bacteria and viruses that elevate body temperature

117b

Radiation

118a

Transfer of heat from the surface of one object to the surface of another with our direct contact

118b

Shivering

119a

Involuntary body response to temperature differences in the body

119b

State the formulas for the following conversions. Celsius to Fahrenheit

120a

Multiply the Celsius reading by 9/5 and add 32 to the product

120b

State the formulas for the following conversions. Fahrenheit to Celsius

121a

Subtract 32 from the Fahrenheit reading and multiple the result by 5/9

121b

Summarize the treatment for hypothermia.

122a

Remove wet clothes; wrap the patient in blankets

122b

The ability to control body temperature depends on: (4)

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

3. Victims of heat stroke do not sweat

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