Fundamentals of Nursing Study Guide *Q&A* [verified]

Fundamentals of Nursing Study Guide *Q&A* [verified] Assessment: *Ans* collecting vital signs, pain levels, other signs/ symptoms Diagnosis: *Ans* nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis Planning: *Ans* nurse comes up with client-centered goals; need to be measurable (client will ambulate 10 meters 3x daily for 2 wks) Implementing: *Ans* following through with plan that was developed for the patient Evaluation: *Ans* goal was met, partially met, not met; how effective the plan was for the patient and what should be changed for the patient Normal range for temperature *Ans* 96.8-100.4 Normal range for pulse *Ans* 60-100 Normal range for respirations *Ans* 12-20 Normal range for BP *Ans* 100/60-140-90 Normal range for pulse ox. *Ans* >95% SOLER *Ans* sit close, observe, lean forward, eye contact, relax Types of pain *Ans* acute, chronic, cancer, by inferred pathology, idiopathic Pain threshold *Ans* level of stimulus needed to produce the perception of pain Pain tolerance *Ans* amount of pain a patient endures without its interference of ADLs Factors influencing pain *Ans* age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors Behavioral responses to pain *Ans* clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction Pharmacological pain relief *Ans* analgesics (NSAIDS & non-opioids, opioids, adjuvants