Nursing Practice Exam 1 Vocabulary & Concepts Study Guide

Flashcards testing key vocabulary terms and clinical judgment concepts for Nursing Exam 1 based on the printable study guide.

Assessment (ADPIE)

The first step of the Nursing Process, which involves gathering subjective and objective information about the patient.

Diagnosis (ADPIE)

The second step of the Nursing Process, which involves determining the patient's problems based on assessment findings.

Planning (ADPIE)

The third step of the Nursing Process, which involves setting goals or outcomes and deciding which interventions should be used.

Implementation (ADPIE)

The fourth step of the Nursing Process, which involves performing the planned nursing interventions.

Evaluation (ADPIE)

The final step of the Nursing Process, which involves determining whether expected patient outcomes were met.

Recognizing Cues

The Clinical Judgment Model step that corresponds to Assessment in the Nursing Process.

Analyzing Cues

The Clinical Judgment Model step that corresponds to Diagnosis in the Nursing Process, involving the interpretation of assessment data.

Prioritizing Hypotheses

The Clinical Judgment Model step that corresponds to Diagnosis in the Nursing Process, involving ranking identified patient issues.

Generating Solutions

The Clinical Judgment Model step that corresponds to Planning in the Nursing Process, focusing on identifying actions to achieve goals.

Taking Action

The Clinical Judgment Model step that corresponds to Implementation in the Nursing Process.

Evaluating Outcomes

The Clinical Judgment Model step that corresponds to Evaluation in the Nursing Process, measuring clinical results against expectations.

ISBAR Communication

A structured communication tool comprising Identify, Situation, Background, Assessment, and Recommendation to transfer key patient information.

Identify (ISBAR)

The component of ISBAR where the nurse states their name, role, location, and patient identification.

Situation (ISBAR)

The component of ISBAR describing what is currently happening and why the healthcare provider is being contacted.

Background (ISBAR)

The component of ISBAR providing relevant medical history, diagnosis, medications, and admission reason/recent events.

Assessment (ISBAR)

The component of ISBAR where the nurse reports current findings, clinical measurements, and what they suspect is occurring.

Recommendation (ISBAR)

The component of ISBAR where the nurse states what action, request, or response is needed next.

Hand-Off Report

A transfer-of-care report communicating essential information such as patient identification, current condition, safety concerns, equipment, and plan of care to the receiving nurse.

Therapeutic Communication

Patient-centered interaction techniques—such as active listening, open-ended questions, silence, reflection, and empathy—designed to encourage patients to express thoughts and feelings.

Teach-Back

A patient education evaluation method where the nurse asks the patient to explain or demonstrate information in their own words to confirm understanding.

Factual Documentation

Objective medical record entries based strictly on what the nurse observed, assessed, performed, or was told, excluding personal opinions or judgmental language.

Nursing Informatics

The integration of technology, data, electronic health records, and clinical decision-support systems to improve patient safety and maintain privacy.

Least Restrictive Interventions

Alternative safety measures—such as frequent observation, reorientation, toileting, moving closer to the nurses' station, or family presence—attempted prior to applying restraints.

Restraints

Physical or chemical measures used only when clinically necessary as a last resort under provider orders, applied for the shortest time necessary with continuous monitoring.

Morse Fall Risk Scale

An assessment tool evaluating six categories: history of falling, secondary diagnosis, ambulatory aid, IV therapy, gait, and mental status to determine fall risk.

Timed Up and Go (TUG)

An assessment of functional mobility where a patient stands from a chair, walks a short distance, turns around, walks back, and sits down while being observed for balance and stability.

STEADI

An acronym for 'Stopping Elderly Accidents, Deaths & Injuries,' a CDC initiative focused on fall prevention in older adults using a Screen, Assess, and Intervene approach.

Qualified Medical Interpreter

A trained professional required for healthcare discussions with patients who have limited English proficiency, as opposed to relying on children or family members.

Cultural Humility

A nursing care approach that emphasizes asking patients about their individual cultural preferences, practices, and beliefs rather than relying on assumptions or stereotypes.