Study Guide 2026 | Key
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,Assessment: collecting vital signs, pain levels, other signs/ symptoms
Diagnosis: nurse makes a nursing diagnosis based on assessment of patient; not a medical
diagnosis
Planning: nurse comes up with client-centered goals; need to be measurable (client will
ambulate 10 meters 3x daily for 2 wks)
Implementing: following through with plan that was developed for the patient
Evaluation: 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 96.8-100.4
Normal range for pulse 60-100
Normal range for respirations 12-20
Normal range for BP 100/60-140-90
Normal range for pulse ox. >95%
SOLER sit close, observe, lean forward, eye contact, relax
Types of pain acute, chronic, cancer, by inferred pathology, idiopathic
Pain threshold level of stimulus needed to produce the perception of pain
Pain tolerance amount of pain a patient endures without its interference of ADLs
Factors influencing pain age, fatigue, genes, neurological functions, social factors, spiritual factors,
psychological factors, cultural factors
, Behavioral responses to pain 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 analgesics (NSAIDS & non-opioids, opioids, adjuvants)
NSAIDS & non-opiates has analgesic/ antipyretic effects; available OTC; used for moderate to mild pain;
blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed;
do not take with alcohol; do not take if liver dysfunction, possible liver failure
Opioids pain relivers that contain opium or chemically related to opium; ordered for
moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses
respiratory center, causes constipation, itching, altered mental status
Naloxone (Narcan) opiate antagonist, reverses opioid induced resiratory depression
Patient Controlled Analgesia (PCA) client has control with minimum risk of overdose; system designed to deliver no
more than specific number of doses
Anesthetics depresses CNS from consciousness to unconsciousness; loss of responsiveness to
sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle
relaxation; general or local
Basal metabolic rate (BMR) energy needed to maintain life
Carbohydrates main source of energy; glucose needed for brain, skeletal muscles, production of
RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk,
sugar, honey
Proteins essential from growth, maintenance, and repair of body tissue; amino acids;
complete and complementary; nitrogen balance
Fats triglycerides and fatty acids; saturated or unsaturated; monounsaturated or
polyunsaturated fatty acids; essential or nonessential
Water comprises 60-70% of body weight; cell function depends on a fluid environment,
you can only survive a few days without it, illness increases need for fluids
Vitamins essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except
D; water soluble(C and B complex) cannot be stored in body; obtained from fruits,
milk, veggies, fish, cereal, grains, nuts, sunlight
Minerals inorganic elements essential as catalysts in biochemical reactions; obtained in milk,
eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen
transport
Free Radical Theory presence of free radicals produced through normal respiration and metabolism
cause damage to existing cells, some believe this can be reversed through
consumption of vitamins and other products