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Exam (elaborations)

NU 231 Exam 1 Study Questions and Correct Answers

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  • Course
  • NUR 231
  • Institution
  • NUR 231

What are the vital signs we assess? Temperature Pulse Respirations Blood Pressure Pain O2 What is a normal temperature? 37 C or 98.6 F What is a normal pulse? 60-100 bpm What is a normal respiration rate? 12-20 breaths per minute What is normal blood pressure? 120/80 mmHg How do we ask patient...

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  • September 5, 2024
  • 11
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • NUR 231
  • NUR 231
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NU 231 Exam 1 Study Questions and
Correct Answers
What are the vital signs we assess? ✅Temperature
Pulse
Respirations
Blood Pressure
Pain
O2

What is a normal temperature? ✅37 C or 98.6 F

What is a normal pulse? ✅60-100 bpm

What is a normal respiration rate? ✅12-20 breaths per minute

What is normal blood pressure? ✅120/80 mmHg

How do we ask patients to rate pain? ✅on a 0-10 pain scale

children often use face scale

neonates: Neonatal Infant Pain Scale (NIPS) or Neonatal Pain, Agitation and Sedation
Scale (N-PASS)

Nursing action for abnormal vitals ✅- Always retake them first
- Report any abnormal findings
- Follow principles of delegation
- Validate abnormal findings and further assess

When do we assess vital signs? ✅-Upon admission to any healthcare facility.
-Based on policy and procedures.
- Any time there is a loss in consciousness
-Any time there is a change in the patient's condition.
-Before and after surgical or invasive diagnostic procedures.
-Before and after activity that may increase risk, such as ambulation after surgery.
-Before and after administering medications that affect cardiovascular or respiratory
functioning.

What are the sources of heat production? ✅- The primary source is metabolism.
- Hormones, muscle movements and exercise can all increase metabolism.
- Epinephrine and norepinephrine are released when additional heat is required and
alter metabolism

, - Thyroid hormone and shivering increases heat production
- Energy production decreases and heat production increases

What are the sources of heat loss? ✅- Skin (primary source)
- Evaporation of sweat
- Warming and humidifying inspired air
- Eliminating urine and feces
- Transfer of body heat to environment

How is body heat transferred to the environment? ✅Radiation
Convection
Evaporation
Conduction

What affects body temperature? ✅- Circadian rhythm: body temp. is lower in morning
and higher between 4 and 8pm

- Age & Gender: Older adults have less subcutaneous tissue, this leads to loss of
thermoregulatory function. New borns are more susceptible to heat loss. Women
experience more temp. fluctuations than men

- Physical Activity: Muscle movement increases temp.

- State of Health: Certain disease processes can result in a change of body temp.

- Environmental Temp.: Hypothermia and Hyperthermia

How is pulse regulated? ✅By the autonomic nervous system through the SA node of
the heart

Define pulse rate ✅The number of contractions over a peripheral artery in 1 minute

Parasympathetic stimulation vs. sympathetic simulation (HR) ✅Parasympathetic
Stimulation = decrease in HR
Sympathetic Stimulation = increase in HR

List 3 ways to assess pulse ✅1. Palpate the peripheral arteries
2. Auscultate the apical pulse with a stethoscope
3. Use a portable Doppler ultrasound

List the common pulse sites ✅Temporal
Carotid (often used during cardiac arrest)
Brachial (commonly done on infants)
Radial (normal for adults)

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