NUR 103- Exam 3 (Answered) 183
Questions and Correct Answers, 100%
Correct, Latest 2024/2025.
Vital signs
indicators of physiologic functioning; body temperature, pulse, respiratory rates, and blood pressure
Pulse (P)
-pulse (peripheral): a throbbing sensation that can be palpated over a peripheral artery, such as the
radial or carotid artery
-pulse pressure: the difference between systolic and diastolic pressure
Respirations (R)
-act of breathing and using oxygen in body cells
-inspiration: act of breathing in; inhalation
-expiration: act of breathing out; exhalation
Apnea
absence of breathing
Orthopnea
a condition in which people with dyspnea can often breathe more easily in an upright position
Conversions for temperature
Celcius to Fahrenheit: x 9/5 + 32
Fahrenheit to Celcius: - 32 x 5/9
Normal Temperature by Age
Newborn (0-28 days): Axillary: 35.9-36.9 or 96.7-98.5
Infants (1-12 months): Temporal: 37.1-38.1 or 98.7-100.5
Toddler (1-3 years): Temporal: 37.1-38.1 or 98.7-100.5
Child (4-10 years): Tympanic: 36.8-37.8 or 98.2-100
Preteen (11-12 years): Oral: 35.8-37.5 or 96.4-99.5
Teen (13-19 years): Oral: 35.8-37.5 or 96.4-99.5
Adult (20-64 years): Oral: 35.8-37.5 or 96.4-99.5
Aged Adult (65+): Oral: 35.8-36.8 or 96.4-98.3
Normal Pulse by Age
Newborn (0-28 days): 70-190
Infants (1-12 months): 80-160
Toddler (1-3 years): 80-130
Child (4-10 years): 70-115
Preteen (11-12 years): 65-110
,Teen (13-19 years): 55-105
Adult (20-64 years): 60-100
Aged Adult (65+): 40-100
Normal Respirations by Age
Newborn (0-28 days): 30-40
Infants (1-12 months): 20-40
Toddler (1-3 years): 25-32
Child (4-10 years): 20-26
Preteen (11-12 years): 18-26
Teen (13-19 years): 12-22
Adult (20-64 years): 12-20
Aged Adult (65+): 16-24
Normal Blood Pressure by Age
Newborn (0-28 days): 73/55
Infants (1-12 months): 85/37
Toddler (1-3 years): 89/46
Child (4-10 years): 95/57
Preteen (11-12 years): 102/61
Teen (13-19 years): 112/64
Adult (20-64 years): 120/80
Aged Adult (65+): 120/80
Health Assessment
-includes a health history, vital signs, and physical assessment
-questions: about patient subjective and objective data
-includes 4 types: comprehensive, ongoing, focused, emergency
Comprehensive health assessment
-detailed history and physical examination at onset of care in primary care setting or on admission to
hospital or long-term care facility; encompasses health problems, health promotion, disease
prevention, and assessment for problems associated with known risk factors
-goal is to find the baseline data
Ongoing health assessment
monitor changes after receiving interventions
Focused health assessment
Assessment based on the patient's problems; components include performing a general survey,
taking vital signs, and assessing specific areas that relate to the problem
Emergency health assessment
conducted to determine life-threatening or unstable conditions
What is the purpose of the physical assessment?
,-to gather objective data to identify physical changes in the patient
-this information, along with subjective data, is used to formulate diagnoses
Equipment needed for a physical assessment
-thermometer
-sphygmomanometer
-scale
-penlight
-stethoscope
-metric tape measure and ruler
-eye chart
-tuning fork
Order of techniques for a physical assessment
1. inspection
2. palpation
3. percussion
4. auscultation
Inspection
-seeing; deliberate and methodical
Palpation
-feeling; using finger pads and dorsum of hand
Percussion
-sound- tapping fingers
Auscultation
-hearing; utilizing stethoscope
-pitch, loudness, duration, quality
-ex: abdominal sound is gurgling, loud, and high pitched for 2 seconds
When is it appropriate to measure vital signs?
-in the home
-screenings at health care facilities and clinics
-upon admission and before discharge
-when medications are given that can affect cardiac rhythms
-before and after any invasive or surgical procedure
-in emergency situations
-when patient condition changes
Temperature (T)
-controlled in the hypothalamus: which is a thermoregulatory center that sends messages to gain or
lose heat
-heat is a byproduct of metabolic activity on the cellular level
-normal oral temp for an adult is 37 C (98.6 f)
, What are factors that affect body temperature?
-circadian rhythms (more in infants and children)
-age & gender (women due to hormone cycles, infants and older adults due to environmental
changes)
-physical activity (more activity=more body heat; increased metabolism)
-state of health- disease
-environmental temperature- (hypothermia/hyperthermia)
Increased body temperature
-cause: pyrogens, chemicals, environment
-> 41 C = hyperpyrexia (can cause brain damage)
-effects: first shivering, piloerection, & vasoconstriction (increased metabolism) then sweating,
vasodilation, increased RR
-Increased RR & P, loss of appetite, headache, hot/dry skin, flushed face, thirst, muscle aches fatigue
-treatment: cool environment, cooling blanket, ice packs, cool bath, increase oral fluids, simple
carbs, antipyretic medications, antibiotics
Decreased body temperature
-cause: exposure, chronic conditions
-older adults: impaired perception, accidental
-temperature below 35 C can result in death
-effects: poor coordination, slurred speech, poor judgement, amnesia, hallucinations, stupor,
decrease RR, pulse weak and irregular, low BP
-treatment: rewarm with blankets, clothing, heating pads, radiant warmer, warm fluid intake
Assessing temperature
-action of taking a temperature can be delegated
nurse responsibilities
-assessing: findings, effect of changes in body temp
-implementing interventions
-teaching patient about: methods of temperature measurement, normal values, and abnormal
values
Equipment for Temperature
Electronic and digital- oral, axillary, rectal
Tympanic membrane
Disposable single use- no cross contamination, forehead/ abdomen
Temporal artery- as accurate as oral and more than axillary and tympanic
Automated monitoring device- measures all 4 vitals without time investment
Oral Temperature
-35.8-37.5
-under the tongue
-wait 15 minutes after eating, chewing gum, or smoking
Contraindications:
-oral or nasal surgery
Questions and Correct Answers, 100%
Correct, Latest 2024/2025.
Vital signs
indicators of physiologic functioning; body temperature, pulse, respiratory rates, and blood pressure
Pulse (P)
-pulse (peripheral): a throbbing sensation that can be palpated over a peripheral artery, such as the
radial or carotid artery
-pulse pressure: the difference between systolic and diastolic pressure
Respirations (R)
-act of breathing and using oxygen in body cells
-inspiration: act of breathing in; inhalation
-expiration: act of breathing out; exhalation
Apnea
absence of breathing
Orthopnea
a condition in which people with dyspnea can often breathe more easily in an upright position
Conversions for temperature
Celcius to Fahrenheit: x 9/5 + 32
Fahrenheit to Celcius: - 32 x 5/9
Normal Temperature by Age
Newborn (0-28 days): Axillary: 35.9-36.9 or 96.7-98.5
Infants (1-12 months): Temporal: 37.1-38.1 or 98.7-100.5
Toddler (1-3 years): Temporal: 37.1-38.1 or 98.7-100.5
Child (4-10 years): Tympanic: 36.8-37.8 or 98.2-100
Preteen (11-12 years): Oral: 35.8-37.5 or 96.4-99.5
Teen (13-19 years): Oral: 35.8-37.5 or 96.4-99.5
Adult (20-64 years): Oral: 35.8-37.5 or 96.4-99.5
Aged Adult (65+): Oral: 35.8-36.8 or 96.4-98.3
Normal Pulse by Age
Newborn (0-28 days): 70-190
Infants (1-12 months): 80-160
Toddler (1-3 years): 80-130
Child (4-10 years): 70-115
Preteen (11-12 years): 65-110
,Teen (13-19 years): 55-105
Adult (20-64 years): 60-100
Aged Adult (65+): 40-100
Normal Respirations by Age
Newborn (0-28 days): 30-40
Infants (1-12 months): 20-40
Toddler (1-3 years): 25-32
Child (4-10 years): 20-26
Preteen (11-12 years): 18-26
Teen (13-19 years): 12-22
Adult (20-64 years): 12-20
Aged Adult (65+): 16-24
Normal Blood Pressure by Age
Newborn (0-28 days): 73/55
Infants (1-12 months): 85/37
Toddler (1-3 years): 89/46
Child (4-10 years): 95/57
Preteen (11-12 years): 102/61
Teen (13-19 years): 112/64
Adult (20-64 years): 120/80
Aged Adult (65+): 120/80
Health Assessment
-includes a health history, vital signs, and physical assessment
-questions: about patient subjective and objective data
-includes 4 types: comprehensive, ongoing, focused, emergency
Comprehensive health assessment
-detailed history and physical examination at onset of care in primary care setting or on admission to
hospital or long-term care facility; encompasses health problems, health promotion, disease
prevention, and assessment for problems associated with known risk factors
-goal is to find the baseline data
Ongoing health assessment
monitor changes after receiving interventions
Focused health assessment
Assessment based on the patient's problems; components include performing a general survey,
taking vital signs, and assessing specific areas that relate to the problem
Emergency health assessment
conducted to determine life-threatening or unstable conditions
What is the purpose of the physical assessment?
,-to gather objective data to identify physical changes in the patient
-this information, along with subjective data, is used to formulate diagnoses
Equipment needed for a physical assessment
-thermometer
-sphygmomanometer
-scale
-penlight
-stethoscope
-metric tape measure and ruler
-eye chart
-tuning fork
Order of techniques for a physical assessment
1. inspection
2. palpation
3. percussion
4. auscultation
Inspection
-seeing; deliberate and methodical
Palpation
-feeling; using finger pads and dorsum of hand
Percussion
-sound- tapping fingers
Auscultation
-hearing; utilizing stethoscope
-pitch, loudness, duration, quality
-ex: abdominal sound is gurgling, loud, and high pitched for 2 seconds
When is it appropriate to measure vital signs?
-in the home
-screenings at health care facilities and clinics
-upon admission and before discharge
-when medications are given that can affect cardiac rhythms
-before and after any invasive or surgical procedure
-in emergency situations
-when patient condition changes
Temperature (T)
-controlled in the hypothalamus: which is a thermoregulatory center that sends messages to gain or
lose heat
-heat is a byproduct of metabolic activity on the cellular level
-normal oral temp for an adult is 37 C (98.6 f)
, What are factors that affect body temperature?
-circadian rhythms (more in infants and children)
-age & gender (women due to hormone cycles, infants and older adults due to environmental
changes)
-physical activity (more activity=more body heat; increased metabolism)
-state of health- disease
-environmental temperature- (hypothermia/hyperthermia)
Increased body temperature
-cause: pyrogens, chemicals, environment
-> 41 C = hyperpyrexia (can cause brain damage)
-effects: first shivering, piloerection, & vasoconstriction (increased metabolism) then sweating,
vasodilation, increased RR
-Increased RR & P, loss of appetite, headache, hot/dry skin, flushed face, thirst, muscle aches fatigue
-treatment: cool environment, cooling blanket, ice packs, cool bath, increase oral fluids, simple
carbs, antipyretic medications, antibiotics
Decreased body temperature
-cause: exposure, chronic conditions
-older adults: impaired perception, accidental
-temperature below 35 C can result in death
-effects: poor coordination, slurred speech, poor judgement, amnesia, hallucinations, stupor,
decrease RR, pulse weak and irregular, low BP
-treatment: rewarm with blankets, clothing, heating pads, radiant warmer, warm fluid intake
Assessing temperature
-action of taking a temperature can be delegated
nurse responsibilities
-assessing: findings, effect of changes in body temp
-implementing interventions
-teaching patient about: methods of temperature measurement, normal values, and abnormal
values
Equipment for Temperature
Electronic and digital- oral, axillary, rectal
Tympanic membrane
Disposable single use- no cross contamination, forehead/ abdomen
Temporal artery- as accurate as oral and more than axillary and tympanic
Automated monitoring device- measures all 4 vitals without time investment
Oral Temperature
-35.8-37.5
-under the tongue
-wait 15 minutes after eating, chewing gum, or smoking
Contraindications:
-oral or nasal surgery
