Vital Signs & Baseline Measurements
The expected normal core body temperature range for an adult client.
What is 36°C to 38°C (96.8°F to 100.4°F)?
The fundamental clinical rule regarding pain assessment, defined as whatever the experiencing person says it is
What is pain is a subjective experience?
The type of question a nurse should use to elicit detailed information rather than a simple "yes" or "no" (e.g., "Tell me how you are feeling today").
What is an open-ended question?
The ethical principle defined as the nurse's duty to do good and actively relieve client suffering.
What is Beneficence?
The expected physiological baseline difference in core body temperature commonly seen in older adult clients.
What is a slightly lower baseline body temperature?
The expected resting respiratory rate range for an adult, which should be counted without informing the client when possible.
What is 12 to 20 breaths per minute?
In the PQRST pain assessment mnemonic, the letters P and R stand for these components.
What are Precipitating/Provoking factors and Region/Radiation?
The communication technique where the nurse repeats or rephrases the client's statements to confirm understanding.
What is restating or paraphrasing?
The ethical principle that protects a client's right to make autonomous, informed decisions regarding their healthcare.
What is Autonomy
In older adults with systemic infections or UTIs, the nurse must remember that this classic sign may be entirely absent.
What is a fever (pyrexia)?
The clinical error caused by applying a blood pressure cuff that is too small or narrow for the client's arm.
What is a falsely high / elevated blood pressure reading?
Pain originating from bone, muscle, or visceral tissue that is typically described as aching or throbbing.
What is nociceptive pain?
When communicating with an older adult who has hearing loss, the nurse should adopt this vocal pitch and position.
What is facing the client directly and speaking in a lower pitch (without shouting)?
The ethical principle of "doing no harm," which includes avoiding both medication errors and undertreating client pain.
What is Nonmaleficence?
To accurately assess skin turgor and hydration in an older adult, the nurse should test over these anatomical locations rather than the back of the hand.
What are the sternum or clavicle?
The exact anatomical landmark used to locate the adult apical pulse, which must be auscultated for 1 full minute if the radial rate is irregular.
What is the 5th intercostal space at the left midclavicular line?
The behavioral pain assessment tool (Face, Legs, Activity, Cry, Consolability) used for young children or nonverbal/cognitively impaired clients.
What is the FLACC scale?
The mandatory protocol when providing education or collecting data from a client who speaks a different language.
What is using a qualified facility interpreter (never family members or adult children)
The legal designation for professional negligence by a licensed nurse who fails to meet established standards of care.
What is malpractice?
Nonverbal behavioral cues that indicate pain in a client with advanced dementia who cannot self-report.
What are guarding, grimacing, agitation, withdrawal, or changes in sleep/appetite?
The metric calculated by subtracting the radial pulse rate from the apical pulse rate, indicating conditions such as atrial fibrillation or cardiac dysrhythmias.
What is a pulse deficit?
Pain that originates in one organ or location but is felt in another area, such as gallbladder pain radiating between the shoulder blades.
What is referred pain?
The professional communication style that expresses boundaries clearly and respectfully without being passive or aggressive.
What is assertive communication?
To maintain professional boundaries, nurses must avoid these actions with current or former clients.
What are sharing personal phone numbers/social media or accepting personal gifts?
The step-by-step blood pressure sequence used to evaluate for orthostatic hypotension and fall risk.
What is measuring blood pressure while lying, sitting, and standing (waiting 1 minute between changes)?