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NUR 213 ( LATEST 2024 / 2025 ) EXAM 8 | COMPLETE ANSWERS 100% CORRECT
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NUR 213 ( LATEST 2024 / 2025 ) EXAM 8 | COMPLETE ANSWERS 100% CORRECT
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NUR 213 Exam 81. What are vital signs
The vital signs + Reference range
Answer
Clinical measurements that guide treatment decisions and interventions; know patient's baseline
to compare to future findings
1) Blood pressure
measurement of the force or pressure of the circulating blood on the interior walls of the blood
vessels (120/80 mm Hg)
2) Pulse
the rhythmic dilation of the arteries that occurs with the beating of the heart (60-100 BPM) (can
be regular or irregular)
3) Body Temperature
balance of heat produced by the body and heat lost to the environment (96.8-100.4 F) (36-38 C)
-avg
37 C or 98.6 F
4) Respiratory rate (RR)
number of breaths per minute (12-20 BMP)
-measure for rate, depth and rhythm*
-can be irregular/regular, shallow/deep
5) Oxygen Saturation (SaO2)
estimated amount of oxygen bound to the hemoglobin molecule in RBCs, indicating the amount
of oxygen being transported (95-100%)
6) Pain* sometimes
2. Blood Pressure Systolic vs Diastolic
Pulse pressure
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,Answer
Systolic BP
the maximum amount of pressure exerted when the heart contracts and forces blood into the
aorta
Diastolic BP
the minimum amount of pressure exerted when the heart is relaxed reported in mm Hg,
expressed in systolic over diastolic
Pulse pressure
the difference between the systolic and diastolic pressures
3. Hypertension
Answer
A BP above the expected reference range, sigificantly increases a clients risk for major health
problems like heart attack and stroke
Elevated
-systolic of 120 to 129 mm Hg
-Diastolic of less than 80
Stage 1
-systolic pressure
130 to 139mm Hg
-diastolic pressure
80 to 89 mm Hg
Stage 2
-systolic pressure > 140mm Hg
-diastolic pressure > 90mm Hg
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,Hypertensive crisis
-systolic > 180mm Hg
-diastolic > 120 mm Hg
4. Nursing interventions for hypertension
Answer
-Encourage the client to adopt lifestyle interventions such as exercise, stress reduction
techniques, a low-sodium diet, and weight loss if needed.
-Provide the client with information about
antihypertensive medications, if prescribed by the provider, including expected adverse effects
and when the provider should be notified
Predisposing factors
Answer
-genetics, poor diet, lack of exercise, stress, alcohol, certain medications
5. Hypotension
manifestations
interventions
Answer
A BP that is below the expected reference range as determined by a client's usual baseline
measurement
In absence of a baseline
Answer
-systolic pressure < 90mm Hg
-diastolic pressure <60mm Hg
Manifestations
Answer
-dizziness, nausea, blurred vision, increased pulse, fatigue
-*major fall risk (might pass out or from dizziness)
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, Causes
Answer
-can be caused from vasodilation (allergic reactions), dehydration, medications, blood loss,
shock, significant illness
Interventions
Answer
-Increase fluids, stay well hydrated
-Place in an upright position unless medically contraindicated
-Evaluate the medications the client is taking
-Instruct the client about the risk for dizziness and falling
-Encourage the client to change positions slowly
-Avoid extremes in temperature
6. Analysis of Blood pressure alterations
Answer
Age
Answer
-Infants have a low BP that gradually increases with age
-Older children have varying BP based on body size
-Adults BP can increase with age
-Older adults have slightly elevated systolic pressure due to decreased elasticity of blood vessels
-Circadian rhythms (BP is usually lowest in early morning)
-Stress
Answer
fear, emotional strain, and acute pain can increase BP
-Ethnicity
Answer
African American have higher incidence of hypertension
-Sex
Answer
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