PNR 110 Test 2 UPDATED ACTUAL Questions and CORRECT
Answers
What are the 5 vital signs? Temperature, pulse, respiration, blood pressure, pain level
What vital signs change with age? Temperature
Lower metabolic rate
Respiratory rate
Blood pressure
Factors affecting body heat production -thyroid hormone, epinephrine, norepinephrine, testosterone, gender, voluntary
muscle movement, shivering
Heat loss occurs with skin's exposure to the environment radiation, conduction, convection, evaporation
through ___ (4)
How temperatures vary depending on site Rectal: temp about 1 degree higher than oral
Axillary: temp about 1 degree lower than oral
What does the tympanic membrane measure? The approximate core body temperature
Factors affecting temperature measurements -time of day (circadian rhythm)
-environmental temperature
age of the patient
-physical exercise
-menstrual cycle and pregnancy
-emotional stress
-disease conditions
-drugs
-eating, drinking, mouth breathing
What's the difference between hyperthermia and Hyperthermia is a temp about normal range (fever, pyrexia, febrile state)
hypothermia Hypothermia is lowering of the temperature of entire body
Who are people at risk for hypothermia? -infants
-surgical patient in the operating room
-elderly exposed to cold for prolonged periods
-people exposed to extreme cold weather
-people exposed to cold water immersion
What are some nursing interventions for reducing fever? -increase patient's fluid intake
-lower room temp.
-increase the rate of circulating air
-remove excessive clothing or sheets
-reduce the amount of body activity
-provide sponge bath and cooling blanket
-antipyretics (acetaminophen)
, How to take rectal temperature • Provide privacy
• Drape the patient to reveal only the anal area.
• Don gloves.
• Lubricate tip of the thermometer or probe
• Hold the thermometer in place for 3 to 5 minutes oruntil the correct temperature
is indicated.
• Wipe the thermometer or probe from the stem towardthe bulb or probe tip.
• Wipe the buttocks to remove lubricant or stool.
• Correctly dispose of tissues and gloves.
• Wash hands
Define pulse cardiac contractions causing a pressure wave against the walls of arteries
Factors affecting pulse rate -age
-body build and size
-BP
-drugs
-emotions
-blood loss
-exercise
-increased body temp
-pain
-hypoxia
Respiratory sounds Crackles: abnormal, nonmusical
Rhonchi: continuous dry, rattling
Stertor: snoring sound
Stridor: crowing sound on inspiration
Wheeze: whistling sound
Assessment of the areas of basic needs "RNS HOPE"
-Rest and activity
◦ Nutrition, fluids, and electrolytes
◦ Safety and security
◦ Hygiene
◦ Oxygenation
◦ Psychosocial and learning
◦ Elimination
What are physical examination techniques Inspection
Observation
Palpation
Percussion
Auscultation
Elements of a basic physical examination -height and weight
-vital sign measurement
-review of body systems (head, neck, chest, heart, lungs, skin, extremities,
abdomen, genitalia)
Answers
What are the 5 vital signs? Temperature, pulse, respiration, blood pressure, pain level
What vital signs change with age? Temperature
Lower metabolic rate
Respiratory rate
Blood pressure
Factors affecting body heat production -thyroid hormone, epinephrine, norepinephrine, testosterone, gender, voluntary
muscle movement, shivering
Heat loss occurs with skin's exposure to the environment radiation, conduction, convection, evaporation
through ___ (4)
How temperatures vary depending on site Rectal: temp about 1 degree higher than oral
Axillary: temp about 1 degree lower than oral
What does the tympanic membrane measure? The approximate core body temperature
Factors affecting temperature measurements -time of day (circadian rhythm)
-environmental temperature
age of the patient
-physical exercise
-menstrual cycle and pregnancy
-emotional stress
-disease conditions
-drugs
-eating, drinking, mouth breathing
What's the difference between hyperthermia and Hyperthermia is a temp about normal range (fever, pyrexia, febrile state)
hypothermia Hypothermia is lowering of the temperature of entire body
Who are people at risk for hypothermia? -infants
-surgical patient in the operating room
-elderly exposed to cold for prolonged periods
-people exposed to extreme cold weather
-people exposed to cold water immersion
What are some nursing interventions for reducing fever? -increase patient's fluid intake
-lower room temp.
-increase the rate of circulating air
-remove excessive clothing or sheets
-reduce the amount of body activity
-provide sponge bath and cooling blanket
-antipyretics (acetaminophen)
, How to take rectal temperature • Provide privacy
• Drape the patient to reveal only the anal area.
• Don gloves.
• Lubricate tip of the thermometer or probe
• Hold the thermometer in place for 3 to 5 minutes oruntil the correct temperature
is indicated.
• Wipe the thermometer or probe from the stem towardthe bulb or probe tip.
• Wipe the buttocks to remove lubricant or stool.
• Correctly dispose of tissues and gloves.
• Wash hands
Define pulse cardiac contractions causing a pressure wave against the walls of arteries
Factors affecting pulse rate -age
-body build and size
-BP
-drugs
-emotions
-blood loss
-exercise
-increased body temp
-pain
-hypoxia
Respiratory sounds Crackles: abnormal, nonmusical
Rhonchi: continuous dry, rattling
Stertor: snoring sound
Stridor: crowing sound on inspiration
Wheeze: whistling sound
Assessment of the areas of basic needs "RNS HOPE"
-Rest and activity
◦ Nutrition, fluids, and electrolytes
◦ Safety and security
◦ Hygiene
◦ Oxygenation
◦ Psychosocial and learning
◦ Elimination
What are physical examination techniques Inspection
Observation
Palpation
Percussion
Auscultation
Elements of a basic physical examination -height and weight
-vital sign measurement
-review of body systems (head, neck, chest, heart, lungs, skin, extremities,
abdomen, genitalia)
