Nursing Final Exam Study Guide – Vocabulary Flashcards

Traditional vocabulary flashcards covering major nursing process, legal, ethical, communication, teaching, cultural, and safety terms from the study guide.

Assessment

First step of the nursing process; collecting subjective and objective data

Diagnosis

Identifying patient health problems based on assessment findings

Planning

Setting measurable, achievable patient goals and outcomes

Implementation

Carrying out the nursing plan of care

Evaluation

Determining whether goals were met and if plan needs revision

Nursing Process (ADPIE)

Structured framework of Assessment, Diagnosis, Planning, Implementation, Evaluation

Clinical Judgment

Conclusion or decision reached after using the nursing process

Critical Thinking

Logical, evidence-based reasoning used to make decisions

Clinical Reasoning

Applying critical thinking specifically in clinical settings

Evidence-Based Practice (EBP)

Integrating research, clinical expertise, and patient preferences in care

QSEN Competencies

Core skills: Safety, Patient-Centered Care, EBP, Teamwork & Collaboration, Quality Improvement, Informatics

Subjective Data

Information reported by patient (symptoms, feelings, pain)

Objective Data

Measurable or observed information (vital signs, labs, behaviors)

Inpatient Care

Services provided while admitted to a hospital or long-term facility

Outpatient Care

Services such as clinics or same-day surgery without overnight stay

Primary Nursing Model

One nurse has total responsibility for a patient’s care

Team Nursing

Care delivered by a group under an RN’s supervision

Case Management

RN coordinates services to achieve cost-effective outcomes

Cost (Health Economics)

Financial resources required for healthcare delivery

Access (Health Economics)

Ability of individuals to obtain needed healthcare services

Medicare

Federal insurance for adults ≥65 or disabled individuals

Medicaid

State-federal insurance for low-income populations

Private Insurance

Employer-based or individually purchased health coverage

Affordable Care Act (ACA)

Law expanding access to affordable health insurance

Social Determinants of Health

Factors like transportation, education, income, language, housing affecting health

Five Rights of Delegation

Right Task, Circumstance, Person, Direction/Communication, Supervision/Evaluation

Right Task

Delegated activity is appropriate and legal

Right Circumstance

Patient setting and resources make delegation safe

Right Person

Delegatee is competent and allowed to perform task

Right Direction/Communication

Clear, specific instructions are given

Right Supervision/Evaluation

RN monitors, evaluates, and provides feedback on task

Scope of Practice

Activities legally permitted under the Nurse Practice Act

Nurse Practice Act (NPA)

State law defining nursing scope and standards

Board of Nursing

Regulates licensure, scope, and disciplinary actions

SBAR

Structured communication: Situation, Background, Assessment, Recommendation

Closed-Loop Communication

Sender gives message, receiver repeats it back, sender confirms accuracy

Torts

Civil wrongs leading to legal liability

Assault

Threatening to harm a patient

Battery

Unauthorized physical contact with a patient

False Imprisonment

Unjustified restriction of a patient’s freedom of movement

Negligence

Failure to act as a reasonably prudent nurse would

Malpractice

Professional negligence resulting in patient harm

Informed Consent

Patient’s voluntary agreement after understanding procedure and risks

HIPAA

Federal law protecting patient health information privacy

Abandonment

Leaving a patient without adequate notice or replacement

Autonomy

Patient’s right to make their own decisions

Beneficence

Ethical duty to do good for the patient

Nonmaleficence

Ethical duty to do no harm

Justice

Fair and equal treatment of all patients

Fidelity

Keeping promises and commitments to patients

Health Promotion

Activities that prevent illness and improve wellness

Health Literacy

Ability to understand and use health information

Visual Learning Style

Prefers diagrams, written materials, and images

Auditory Learning Style

Learns best through hearing and discussion

Kinesthetic Learning Style

Prefers hands-on activities and movement

Primary Prevention

Actions to prevent disease before it occurs (vaccines, education)

Secondary Prevention

Early detection through screenings (mammograms, BP checks)

Tertiary Prevention

Managing established disease to prevent complications (rehab)

Modifiable Risk Factor

Lifestyle element that can be changed (diet, smoking)

Nonmodifiable Risk Factor

Unchangeable factor like age, genetics, or gender

Cultural Awareness

Recognizing cultural differences without judgment

Cultural Sensitivity

Respecting and accommodating cultural differences

Spiritual Distress

Inner conflict related to personal beliefs or faith

Allergic Reaction

Immune response such as rash or anaphylaxis to a drug

Side Effect

Predictable, often minor effect of a medication

Adverse Effect

Unexpected, harmful reaction to a medication

Toxicity

Harmful drug accumulation in the body

Medication Error

Preventable event that may cause inappropriate medication use or harm

Self-Care Deficit Theory

Orem’s theory that nurses assist when patients cannot meet self-care needs

Hospice Care

Comfort care for terminal illness, typically with <6 months expectancy

Palliative Care

Comfort care at any stage of chronic illness

Kubler-Ross Model

Five stages of grief: Denial, Anger, Bargaining, Depression, Acceptance

Living Will

Document stating desired or refused medical treatments

Durable Power of Attorney

Person designated to make healthcare decisions if patient cannot

Incident Report

Internal document for recording unusual events; not part of chart

Source-Oriented Medical Record

Chart format where each discipline documents in its own section