This episode is a fast, high-yield tour through how real nurses prioritize care, especially under pressure. We break down the “why behind the what” so listeners can stop memorizing random facts and actually understand how to make the safest, fastest decision — exactly what the NCLEX tests. You learn how to distinguish normal versus concerning findings in older adults, when physical danger always beats psychosocial needs, and why environmental safety changes come before anything else. We walk through classic NCLEX traps like climbing over bed rails, sky-high blood pressure during a psychosocial complaint, and postpartum bleeding. You’ll hear the exact priority order for postpartum assessment (fundus → bleeding → pain → ambulation), the correct abdominal exam sequence (inspect → listen → percuss → palpate), and what developmental milestones really mean across childhood. We also hit essential screening rules, when to give the Tdap vaccine, who qualifies for low-dose CT scans, how to size a blood pressure cuff correctly, what slows capillary refill, and what tasks UAPs can and cannot take over. This episode drills the core principle: connect every nursing action to the underlying rationale. That’s what transforms you from task-doer to someone who truly thinks like a nurse — and that’s exactly what helps you pass the NCLEX with confidence.
Less subcutaneous fat
Presbycusis (age-related high-frequency hearing loss)
Reduced vital capacity → gets breathless more easily
Slower gait, unsteady movement
Slower cognitive processing
Mild recent-memory decline
Key nursing actions:
Monitor intake and output
Be cautious with medications cleared by kidneys
Give simple, step-by-step instructions
Assess social support and isolation risk
EN-klex trap:
“Increased gait speed” = NOT normal aging
“Intact recent memory” in older adults = distractor
Scenario: Older adult climbing over raised bed rails
First action: Lower the entire bed
Why:
Fastest way to prevent injury
Environmental change beats calling for help or meds
Restraints require an order and take time
Scenario: Client is sad and lonely but blood pressure is extremely high
First priority: Address the physical threat → recheck BP for accuracy
Reason: Physical instability always beats emotional distress.
Check the fundus — must be firm, midline
Assess lochia — evaluate bleeding
Pain medication
Ambulation
Why: Hemorrhage is the most preventable cause of postpartum death.
Bleeding always comes before pain.
Fundus expectations immediately after birth:
Firm (grapefruit-like)
Midline
At the level of the umbilicus
Drops one finger-width per day
Erikson Examples:
Toddler: Autonomy vs. shame → “NO” stage
Middle adult: Generativity vs. stagnation
Language milestones:
12 months: 1–3 specific words (“mama,” “dada”)
15 months: Same range still acceptable
Preschool thinking:
Imaginary friends = normal
Centration = focuses on one aspect only
Square copying and fully clear speech → later stages
Moro reflex:
Should disappear by 3–4 months
Persistence → neurological red flag
Primary: Prevents disease (vaccines)
Secondary: Early detection (mammograms, colonoscopy, screening CT)
Tertiary: Manage complications (rehab, chronic care)
TDap pregnancy timing:
Give between 27–36 weeks for passive newborn protection
Lung cancer screening:
Ages 50–80
Twenty pack-year history
Current smoker OR quit within last 15 years
Annual low-dose CT
Inspect
Listen
Percuss
Palpate
Reason: Touching stimulates bowels → false readings.
Vesicular = heard best in lung periphery
Bladder should cover 80% of upper arm circumference
Too small → falsely high
Too large → falsely low
Slow if:
Cold
Dehydrated
Poor circulation
Not usually slowed by high blood pressure.
UAP CAN:
Basic hygiene
Meals
Ambulation assistance
Newborn bath
UAP CANNOT:
Fundal assessment
Lochia assessment
Any evaluation
Any teaching
Anything requiring clinical judgment
RN always keeps assessment, evaluation, and teaching.
Scenario: Client has the skills + knowledge to change a colostomy bag but refuses to look at the stoma.
Deficit: Motivation deficit → needs emotional support, not more teaching.
Safety before comfort
Environment adjustments before interventions
Physical danger beats psychosocial needs
Bleeding beats pain
Assessment before action
Rationale behind every step
Think like a nurse, not a task robot
Welcome to Think Like a Nurse. I'm your host and uh today we're really going to get into the thinking behind great nursing care. This whole resource, it's actually created by Brooke Wallace. She's got like 20 years as an ICU nurse, organ transplant coordinator, clinical instructor. She's even a published author. And her mission, our mission really is simple. Take these really complex nursing topics and just well, make them easier to grasp.
Exactly. And that's crucial today because we're doing a bit of a whirlwind tour, a high-speed look at health promotion and maintenance. This means you've got to be ready to switch gears fast, you know, from older adults to newborns and know exactly what to do first when things get critical, right? We're not just about memorizing facts here. We want to pull out the reasons, the critical thinking strategies, the why behind what you actually do at the bedside. And hey, if you find you need more after our chat today, definitely check out think likeyoun.org. Lots more there.
Okay, so let's jump right in. Let's talk about our older patients first. Say a healthy 78-year-old, what are the uh the expected changes we need to keep in mind? Yeah, this is key. Separating what's normal aging from what's actually a problem. So, normally we definitely expect less subcutaneous fat, you know, that padding under the skin. It thins out. We also expect prespicus. That's just the typical age related hearing loss, especially for high frequency sounds. And um reduced vital capacity.
Okay, wait. Reduced vital capacity. Let's break that down. For someone listening, maybe a student at the bedside, what does that actually look like?
It basically just means their maximum lung capacity is lower. So, uh, even if they're healthy, they might get breathless doing things that useded to be easy. It means they have less breathing room, less reserve, and that ties right into, you know, fall risk, how well they oxygenate.
Ah, okay. That connects the dots. Now, what about the common pitfalls? Things students might think are normal aging, but are actually warning signs.
Good question. Big ones are around moving and memory. If you see anything suggesting faster walking speed in an older adult, that's usually wrong. Gate typically slows down, becomes a bit unsteady. and memory. Well, everyone worries about it. And yes, recent memory does tend to decline a bit normally. But if a test question suggests a healthy older adult has perfect recent memory, that's often a distractor, something meant to trip you up.
Makes sense. So linking those normal changes like decreased heart function, kidney function. What are the absolute mustdo nursing actions?
Okay. Definitely monitoring intake and output, really watching hydration, and being careful with meds, especially those cleared by the kidneys. Their thinking might be a bit slower, too. So Uh, keep instruction simple, clear, direct steps, not too many at once. And crucially, always check on their support system. Losing mobility or hearing, that can lead to serious isolation. You need to ask about that.
Okay, let's switch gears fast. Immediate safety. This trumps everything. Picture this. You walk in, 82-year-old client trying to climb over raised bed rails. What is your very, very first move?
Classic priority question. It's always ABC plus safety. Airway, breathing, circulation, safety. The absolute first action. Lower the bed. Get it to the lowest position possible immediately.
Why that specifically? Before, say, trying to grab them or yelling for help?
Because you change the environment first to prevent the injury. Lowering the bed drastically cuts down how far they could fall. Trying to restrain them takes time, might need an order. Giving a med like also needs time and an order. Calling for help is good, but lowering the bed is the fastest, safest, first environmental fix. You do that while calling for help.
Got it. Manipulate the environment for safety. First, that links right into Mathless hierarchy, doesn't it?
So, imagine a 70-year-old client. They tell you they're feeling incredibly sad, lonely, clear, psychosocial need, but their BP is 178 over 96. What gets your attention first?
Uh, the blood pressure. No question. Physiological safety always comes before psychosocial needs on Maslo's hierarchy. That high BP, that's an immediate physical threat, risk to their organs. So, your first action has to address that. Usually, that means re-checking the BP maybe in the other arm just to confirm.
So even if they're clearly distressed emotionally, things like grief counseling, getting a PHQ9, depression screen, talking about meds for sadness,
Uhhuh.
all that waits.
It has to wait until that immediate physical danger is under control or at least assessed properly. You can't really effectively counsel someone who might be having a hypertensive event. Stabilize the physical first.
Okay, let's carry that urgent prioritization mindset over to maternal care. Immediate postpartum. A client is 6 hours out from a vaginal birth. We need to do four things. Check the fundus. Assess the loia. Offer pain meds. Encourage walking. What's the non-negotiable order and why?
The why is simple. Bleeding. Hemorrhage is the biggest preventable killer right after birth. So assessing bleeding risk is number one. Priority one, check the fundus. Make sure that uterus is clamping down. Priority two, assess the loia. Look at the bleeding itself.
Okay, but here's the challenge. What if she's crying out in pain? Isn't that a safety or comfort priority? Shouldn't pain meds come first sometimes? It feels like it should, I know, but no. Pain is critical, yes, but she can bleed out dangerously fast. You must ensure the uterus is firm and the bleeding is controlled before anything else distracts you. So, once you know she's stable from a bleeding standpoint, then priority three is offer pain medication. And finally, priority four is encourage amulation, getting her up to prevent blood clots, life threats first, always.
Bleeding trumps pain. Got it. Crystal clear. And for that very first funal check right after delivery, where should that fundus be? What are we feeling for?
Right after delivery, it should feel firm like a grapefruit. Be right in the middle, midline, and located right at the level of the umbilicus, the belly button.
If it feels boggy, soft, or it's high up, you massage it immediately. After that first check, it should drop about one finger width or 1 cm below the umbilicus each day.
Okay, quick pivot now to PEDs developmental stages. Ericson, that toddler maybe two years old who just said says no to everything. What stage is that?
Oh, yeah. The classic no stage. That's autonomy versus shame and doubt. They're figuring out their their own person. They have some control.
Testing boundaries.
Okay. And jump way ahead. A 45-year-old who maybe regrets not having kids. Feeling like they haven't contributed enough. What's that stage?
That sounds like generativity versus stagnation. Feeling like you've made your mark, contributed to the next generation versus feeling stuck or unproductive.
Let's talk language milestones. A 15-month-old mom says they're saying mama and data specifically to the parents, not just babbling. What milestone does that fit with? That actually aligns typically with the 12 month milestone. Usually 1 to three specific words by then. So at 15 months, they're hitting it maybe a little later than average, but still generally within the normal range. We just watch it.
Okay. Preschoolers now, four years old. What are some normal behaviors that might seem odd to parents or new nurses?
Two things jump out as very normal for four-year-olds. First, imaginary friends. Totally healthy creative play. Second is something called centration. It's a thinking pattern.
Centration. Tell me more.
Yeah. It means they can only focus on one aspect of something at a time. Like if you pour the same amount of juice into a tall thin glass and a short wide glass, they'll often insist the tall glass has more juice. They're focusing only on the height. What's not typically expected at four. Being able to perfectly copy a square that's more like five. Or having speech that's completely easy for strangers to understand. That also develops a bit later. Good distinctions. And neuro checks those primitive reflexes. The mororrow reflex, that startle response where the baby flings their arms out. When should that disappear?
That should be gone. Totally integrated by about 3 to four months old. If you still see a strong moral reflex after 4 months, that's definitely a red flag. Could mean some neurological issue or delay. Needs followup.
All right, let's shift to health maintenance backbone prevention and screening. Primary, secondary, tertiary. Let's get these straight. Quick matches.
Okay. Primary prevent it from happening at all. Protection, so flu vaccine. Secondary, early detection, screening when there are no symptoms. That's your colonoscopy or mammogram. Tertiary, managing an existing disease, minimizing complications, improving quality of life. Think cardiac rehab after a heart attack.
Perfect. Focusing on moms again, TAP vaccine in pregnancy. Specific timing. Why then?
Yep. Ted for protessis. Whooping cough protection for the baby. Give it between 27 and 36 weeks gestation. The timing is key because you want mom to build up antibodies and pass on the placenta to the baby. Gives the newborn protection right from birth before they can get their own shots.
Makes sense. And lung cancer screening for long-term smokers. What's the current recommendation?
right now for adults aged 50 to 80 who have a 20 pack year history. That's like a pack a day for 20 years or two packs a day for 10 years. and either still smoke or quit within the last 15 years. The recommendation is an annual lowdose CT scan of the chest. It's secondary prevention trying to catch it early. Okay. Assessment techniques. Now.
the abdomen. There's a strict rule here in order we absolutely have to follow. What is it?
Oh yeah. Non-negotiable. It's inspect then oscultate then percuss.
Yeah.
Then palpate. Always in that order. I P A P P
I remember learning that. Why is that order so rigid? Why listen before touching?
Because percussing, tapping, and palpating pressing physically moves things around in the belly. It stimulates the bowels. If you do that before you listen, you can totally change the bowel sounds, make them seem more active than they really are. Gives you false information. You got to Listen to the baseline first.
Makes total sense. Okay. Breath sounds, those normal quiet sounds of air moving into the small airways. Vicular sounds. Where do we hear those best?
You hear those best out in the periphery of the lungs. So like the lower loes further away from the big central airways, the trachea and bronchi. Those larger airways have louder, harsher sounds.
Okay. Shifting from procedure to precision now. Getting accurate data. Blood pressure, cuff size, huge deal. What's that key percentage? number we need to remember?
the bladder. The inflatable part of the cuff needs to cover 80% of the circumference of the upper arm. Too small a cuff. Falsely high reading, too big, falsely low. Getting the size right is critical for accurate BP.
Good number to keep in mind. Finally, profusion check. Capillary refill. What makes it slow, longer than like 2 seconds for the color to come back?
Slow cap refill signals poor blood flow, poor profusion. So things like being cold, hypothermia, constricts vessels, dehydration, not enough volume. and peripheral artery disease blockages slowing down flow. Basically states where blood isn't getting to the fingertips well. Interestingly, high blood pressure itself doesn't usually cause slow refill. It's more about volume and flow obstructions.
Okay, last couple of key areas. Delegation and self-care postpartum patient again. What can the UAP, the unlicensed assisted personnel safely do?
Okay, the RN always keeps assessment, evaluation, and teaching. Always. The UAP can definitely handle tasks like basic hygiene, helping with meals, 's activities of daily living. For the baby, a UAP can give the newborn bath, but they absolutely cannot do the fundal massage or assess the loia. Those require clinical judgment, assessing for hemorrhage. That's strictly RN territory.
Big difference between just doing a task and actually assessing. Good point. Now, Dorothia Orum's self-care idea. Client has a new colostomy. They know how to change the bag. You've taught them. They can repeat the steps, but they just refuse to look at the STO. Won't engage. What kind of deficit is that?
According to For him, that's a motivation deficit. They have the knowledge, maybe even the physical skill, but something's blocking them from wanting to do it. It's often about body image acceptance. They need support with the why and the willingness, not just more how-to instructions.
Wow. Okay, we really did cover a lot of ground there from, you know, the subtle cognitive shifts and aging to that immediate safety move, lowering the bed and reinforcing that physical needs like that sky-high BP always come before the psychosocial ones like feeling sad.
Exactly. And we nailed down that postpartum sequence. Fundus, loia, pain, ambulation, and the crucial abdominal assessment order. Inspect, oscultate, percuss, palpate. Remember, IA, PP. I think the biggest thing for you listening is to always connect the why to the what? Critical thinking really hinges on understanding the rationale. Why listen before touching? Why check the fundus first? Why does the BP cuff need to be 80%? Every action should have that principle behind it?
That really is the core of it, isn't it? Understanding the why is what moves you from just doing tasks to truly thinking like a nurse. Well, thank you so much for joining us for this really important conversation.
Yeah, it's been great. We hope you'll check in with us for more conversations each week. And remember, for more essential resources to help you master this stuff, head over to think like a nurse.org.
We'll talk to you next time.