SNB RN Licensure Exam key terms

A systematic, cyclic method of planning and delivering nursing care made up of five phases: assessment, diagnosis, planning, implementation, and evaluation. Each phase depends on the accuracy of the one before it.

The first phase of the nursing process, in which the nurse gathers subjective and objective data about a client's health through interview, observation, physical examination, and review of records.

A clinical judgment about a client's response to actual or potential health problems that guides the selection of nursing interventions. It describes the client's problem, not a medical disease.

The nursing process phase in which the nurse sets client-centered goals and expected outcomes and selects interventions to address identified problems, prioritizing care according to urgency and client preference.

The final nursing process phase in which the nurse compares the client's current status with the expected outcomes to judge whether goals were met, partially met, or unmet, and revises the plan accordingly.

Information a client reports about their own experience, such as pain, nausea, or fatigue, that cannot be directly observed or verified by the nurse. It is obtained mainly through interview.

Measurable, observable information the nurse collects through examination or monitoring, such as vital signs, laboratory values, and wound appearance. It can be verified by more than one observer.

A client's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives. The provider obtains consent; the nurse verifies it and witnesses the signature.

The nurse's ethical duty to protect and promote a client's rights, safety, and preferences, including speaking up when care is unsafe or when the client cannot speak for themselves.

The ethical principle that recognizes a person's right to make their own decisions about their health care, even when the nurse disagrees with the choice, as long as the person is competent.

The ethical principle of acting to promote good and benefit the client. It obligates the nurse to provide care that helps and to weigh benefits against harms.

The ethical principle of avoiding harm or the risk of harm to clients. It underpins practices such as safe medication administration and the duty to report unsafe conditions.

The legal and ethical obligation to protect a client's private health information from unauthorized disclosure, sharing it only with those involved in the client's care or as required by law.

Failure to provide the level of care a reasonably prudent nurse with similar training would provide in similar circumstances, resulting in harm to the client. It requires duty, breach, causation, and damages.

Professional negligence in which a nurse's departure from accepted standards of care causes injury to a client. It is judged against what a competent nurse in the same role would have done.

The range of roles, duties, and activities a nurse is legally authorized to perform, defined by state law, licensure, and professional standards. Performing outside it can endanger clients and the license.

Transferring authority to a competent unlicensed assistive person to perform a specific task while the nurse retains accountability for the outcome. The nurse must assess the client and supervise appropriately.

A federal law that sets national standards for protecting the privacy and security of identifiable health information and defines permitted uses and disclosures, including client rights to access their records.

Infection control practices applied to all clients regardless of diagnosis, including hand hygiene, gloves, gowns, masks, and eye protection when contact with blood or body fluids is anticipated.

Additional infection control measures used for specific pathogens beyond standard precautions, classified by route of spread: contact, droplet, and airborne. Each requires particular barriers and room placement.

Practices that prevent microorganisms from entering the body or a sterile field. Medical asepsis reduces pathogen spread; surgical asepsis keeps objects and areas free of all microorganisms.

Core physiologic measurements, usually temperature, pulse, respiration, blood pressure, and oxygen saturation, that indicate a client's basic body function and detect deterioration or response to treatment.

A drop in blood pressure when moving from lying to sitting or standing, often causing dizziness or fainting. It signals impaired vascular compensation and raises fall risk.

A client's likelihood of falling, increased by factors such as age, sedating medications, weakness, impaired mobility, and orthostatic hypotension. Assessment guides interventions like bed alarms and assistance.

Devices or methods that limit a client's freedom of movement and are used only as a last resort for safety. They require a provider order, defined time limits, frequent monitoring, and release of the limb.

Maintenance of normal body water volume and concentrations of electrolytes such as sodium, potassium, and calcium. Imbalances can disturb nerve, muscle, and cardiac function and require careful monitoring.

Measurement of all fluids a client takes in and eliminates over a period, used to assess fluid status, renal function, and response to therapy such as diuretics or intravenous fluids.

A condition in which the heart cannot pump enough blood to meet the body's needs, causing symptoms such as dyspnea, edema, fatigue, and fluid overload. Management includes medications, diet, and monitoring for worsening.

Abnormally low blood glucose that can cause sweating, tremor, confusion, and seizures. It is treated promptly with fast-acting carbohydrate or glucose, then rechecked.

Giving exogenous insulin to control blood glucose, with careful attention to type, dose, timing, and site rotation. The nurse monitors for hypoglycemia and verifies blood glucose before administration.

The checks a nurse performs before giving a drug: right client, drug, dose, route, and time, plus documentation and reason. Verifying all of them reduces medication errors.

Nursing care after surgery that focuses on airway and breathing, circulation, pain control, wound care, early mobility, and prevention of complications such as infection and blood clots.

A pregnancy disorder marked by new hypertension and proteinuria or organ dysfunction after 20 weeks, which can progress to seizures. It requires close monitoring and often early delivery.

New high blood pressure arising after 20 weeks of pregnancy without proteinuria or other signs of organ damage. It requires monitoring because it may progress to preeclampsia.

Continuous or intermittent recording of the fetal heart rate and uterine contractions to assess fetal well-being and tolerance of labor, guiding timely nursing and medical intervention.

Excessive blood loss after childbirth, commonly from uterine atony, which is a leading cause of maternal death. The nurse assesses fundal tone, lochia, and vital signs and acts quickly.

A structured evaluation of a newborn's transition to extrauterine life, including Apgar scores, vital signs, weight, gestational age, reflexes, and screening for jaundice and feeding readiness.

Nursing assistance that helps a parent establish effective feeding through positioning, latch technique, frequency guidance, and monitoring infant intake and weight gain.

Purposeful use of verbal and nonverbal techniques, such as open-ended questions, reflection, and silence, to build trust and help clients express feelings and concerns.

Fully attending to a client's words and feelings, using eye contact, nods, and clarifying questions, so the client feels heard and the nurse gathers accurate information.

The limits that keep the nurse-client relationship professional and focused on the client's needs, preventing personal, financial, or romantic involvement that could harm or exploit the client.

A structured inquiry into a client's thoughts, plans, means, and intent to harm themselves, along with protective factors, to determine the level of observation and safety measures needed.

A structured assessment of a client's appearance, behavior, mood, affect, thought process and content, cognition, and insight, used to identify psychiatric symptoms and guide care.

Community health actions taken before disease occurs to reduce risk, such as immunization, health education, and safe water programs. It targets whole populations or at-risk groups.

Early detection and prompt treatment of disease to limit its severity, such as screening programs and contact tracing. It aims to catch problems before complications develop.

Rehabilitation and support that reduce disability and help people with established disease function as fully as possible, such as cardiac rehab or support groups.

The study of how disease and health conditions are distributed in populations and what factors influence that distribution, used to plan prevention and control measures.

The number of new cases of a disease arising in a population during a defined period, which reflects the rate at which new illness is occurring.

The total number of existing cases of a disease in a population at a given time, including both new and longstanding cases. It reflects the overall burden of disease.

The ability to provide care that respects and responds to a client's cultural values, beliefs, language, and practices, including recognizing one's own biases and adapting communication.

A person's ability to obtain, understand, and use health information to make decisions. Low health literacy calls for plain language, teach-back, and visual aids.

The sequence required for infection to spread: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Breaking any link prevents transmission.

The legal requirement that nurses report certain conditions to authorities, such as suspected child or elder abuse, communicable diseases, and some injuries, regardless of client wishes.

A state law that establishes the board of nursing, defines nursing practice, and sets requirements for licensure, discipline, and standards of care within that state.