N324 Unit 1 Part 2 - Clinical Judgment, Priority Setting, Communication, Collaboration, Safety & Comfort Vocabulary

Vocabulary flashcards covering key concepts from N324 Unit 1 Part 2 including clinical judgment, CJMM, nursing process, communication, collaboration, safety, and comfort.

Clinical Judgment

Recognizing and interpreting patient information, deciding what is most important, taking action, and evaluating the response.

Clinical Judgment Measurement Model (CJMM)

A six-step model comprised of: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Action, and Evaluate Outcomes.

Recognize Cues

The CJMM step of identifying relevant subjective/objective information such as abnormal findings, changes from baseline, new symptoms, abnormal labs, patient statements, concerns, and history.

Analyze Cues

The CJMM step of connecting findings and asking what cues mean (e.g., fever + elevated WBC + purulent wound drainage indicating infection).

Prioritize Hypotheses

The CJMM step of determining which problem is most likely and most urgent by considering ABCs, acute vs. chronic, actual vs. potential, safety, and unstable vs. stable.

Generate Solutions

The CJMM step of considering appropriate interventions and multiple options before taking action.

Take Action

The CJMM step of safely implementing the priority intervention.

Evaluate Outcomes

The CJMM step of determining whether the intervention worked, reassessing, escalating care when indicated, repeating the clinical judgment process, and modifying the plan if needed.

Critical Thinking

Reasoned thinking based on evidence, openness to alternatives, reflection on assumptions, and a desire to seek truth.

Nursing Process (ADPIE)

A framework defining what nurses do, consisting of Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Subjective Data

Information that the patient directly tells the nurse (e.g., "My pain is 10/10", "My shoulder hurts", "I feel anxious").

Objective Data

Information that the nurse can observe, measure, or verify (e.g., BP 180/90, elevated WBC, grimacing, tenderness on palpation).

Initial Assessment

An assessment that establishes a complete baseline on the first encounter with a patient.

Ongoing Assessment

An assessment that monitors changes and evaluates the effectiveness of interventions over time.

Comprehensive Assessment

An in-depth assessment overview covering all body systems.

Focused Assessment

An assessment that targets a specific problem, system, or concern.

Validation (Data)

The process of double-checking assessment data when subjective and objective data do not agree, information is inconsistent, or values are far outside the normal range.

Medical Diagnosis

The identification of WHAT is wrong medically with the patient (e.g., pneumonia).

Nursing Diagnosis

The identification of HOW the patient responds to a health condition (e.g., ineffective airway clearance).

Assertive Communication

Direct and professional communication style; considered the most positive and acceptable form and expected style on the NCLEX.

Aggressive Communication

A brash communication style that may hinder effective communication.

Passive Communication

A communication style that may lead to an individual becoming the target of another person's frustrations.

Passive-Aggressive Communication

A communication style considered manipulative and unprofessional.

Collaboration

A practice including mutual valuing, recognition of separate and shared responsibilities, safeguarding legitimate interests, and working toward shared goals.

Caring

A core concept central to nursing described as both an art and a science, serving as a moral ideal requiring positive intention and action.

Safety

Focuses on the absence of preventable harm and reduction of risk associated with health care.

Commission Error

An error resulting from doing the wrong action, such as administering the wrong medication.

Omission Error

An error resulting from failing to take an action, such as leaving critical information out of a handoff.

Radiation Precautions

Safety measures summarized by TIME, DISTANCE, and SHIELDING: minimizing time near the source, maximizing distance, and using appropriate shielding/PPE.

Highest-Risk Suicide Situation

A situation characterized by suicidal intent combined with a specific plan and access to means.

Comfort

A dynamic state in which emotional, physical, and spiritual well-being is achieved.

Nociceptors

Sensory receptors that respond to thermal, mechanical, and chemical stimuli.