Exam 1: Fundamentals of Nursing: Communication, Client Education, and Documentation

Vocabulary flashcards covering key nursing concepts, communication models, learning domains, documentation frameworks, and physiological parameters from lecture notes.

Florence Nightingale

A visionary health reformer known as the 'Lady with the Lamp' who brought major reforms in hygiene, sanitation, epidemiology, and education, and established the first organized training school for nurses.

Clara Barton

A Civil War nurse who delivered supplies and care to soldiers on the field and later founded the American Red Cross, whose flag officially flew in the United States in $1881$.

Shannon and Weaver's Communication Model

A linear communication model featuring six core concepts: sender, encoder, channel, decoder, receiver, and noise.

Theodore Newcomb's ABX Model

A social communication model examining communication's role in society, consisting of three components (sender, receiver, and topic) linked by exchange arrows without a separate message placeholder.

David K. Berlo's SMCR Model

A communication model named for its four components—sender, message, channel, and receiver—which incorporates elements that affect messages to illustrate how they aid or hinder communication.

Circular Transactional Model

A continuous, interactive model where each person communicates simultaneously and continuously, featuring components such as referent, sender/receiver, message, channels, feedback, interpersonal variables, and environment.

Referent

The motivator or 'cue' for communication, such as a sight, sound, sensation, or perception, that initiates the conversation.

Assertive Communicator

An effective communicator who expresses needs, rights, and opinions clearly and honestly without violating the rights of others.

Aggressive Communicator

A sender who uses a verbally or physically abusive pattern, blames others using 'you' statements, interrupts, controls, and becomes hostile when challenged.

Passive-Aggressive Communicator

An individual who appears passive on the surface but acts out anger in subtle, indirect, or secretive ways due to underlying feelings of powerlessness and resentment.

Transpersonal Caring

A central concept in Jean Watson's Theory of Human Caring characterized by a human-to-human connection during caring moments aimed at achieving harmony among mind, body, and spirit.

Cognitive Domain of Learning

The 'thinking' domain of learning consisting of six sequential stages: knowledge, comprehension, application, analysis, synthesis, and evaluation.

Affective Domain of Learning

The 'feeling' domain of learning that involves emotions, values, attitudes, and beliefs.

Psychomotor Domain of Learning

The 'doing' domain of learning that involves physical movement, skills, coordination, and sensory integration.

Client Health Literacy

A client's lifelong, evolving ability to obtain, read, and understand health information required to make informed healthcare decisions.

Teach-Back Method

A closed-loop instruction method where a client is asked to explain or demonstrate health information back to the nurse in their own words to confirm comprehension.

Intimate Distance

The zone of personal space spanning from $0\text{ to }18$\,inches.

Personal Distance

The zone of personal space spanning from $18\text{ to }40$\,inches.

Social Distance

The zone of personal space spanning from $4\text{ to }12$\,feet.

Motivational Interviewing (MI)

A nonjudgmental, client-centered communication strategy that uses the patient's goals to motivate positive behavioral and health changes.

Lateral Violence

Workplace bullying, hostile, or aggressive behavior directed by healthcare workers toward their peers.

ISBARR

A standardized communication framework standing for Introduction, Situation, Background, Assessment, Recommendation, and Read back.

Therapeutic Confrontation

A non-hostile communication strategy used to help a client become aware of inconsistencies between their stated beliefs, feelings, and actions.

The Nursing Process

A systematic clinical framework consisting of Assessing (gathering data), Analyzing (identifying problem/nursing diagnosis), Planning (writing care plan), Implementing (carrying out plan), and Evaluating (collecting objective data to determine goal achievement).

Ambient AI Documentation

Technology that functions passively in the background to capture clinical conversations and environmental cues to generate structured clinical notes for EHR integration.

FACT Framework

A structured documentation framework requiring nursing entries to be Factual (objective data), Accurate (exact measurements), Complete (what/when/where/why/how), and Timely (chronological/real-time).

Charting by Exception (CBE)

A documentation method where nurses record only unexpected or abnormal findings outside of established baseline standards or protocols.

Focus Charting (DAR)

A progress note documentation format organized into Data (assessment details), Action (interventions implemented), and Response (evaluation of client outcome).

SOAP Documentation

A problem-oriented progress note format categorized into Subjective data, Objective data, Assessment, and Plan.

PIE Model

A progress note model centered on Problem (nursing diagnosis), Intervention, and Evaluation.

Closed-Loop Communication

A safety process used when receiving verbal or telephone orders in which the nurse transcribes the complete order immediately, reads it back verbatim to the prescriber, and obtains explicit confirmation before execution.

Systolic Pressure

The arterial pressure measured during the contraction of the heart's ventricles.

Diastolic Pressure

The resting arterial pressure measured when the heart's ventricles relax.

SpO2

A noninvasive estimate of peripheral oxygen saturation obtained via a pulse oximeter.

SaO2

The direct measurement of arterial oxygen saturation obtained from arterial blood analysis.