Communication and Documentation Flashcards

A resident tells the nurse aide they do not want their daughter to know about their medical condition. The nurse aide should:

Answer: Honor the resident's request and inform the charge nurse of this preference

Residents have the right to control who receives their health information; this preference should be respected and communicated to the care team.

Which type of communication includes facial expressions, body posture, and eye contact?

Answer: Non-verbal communication

Non-verbal communication encompasses all body language signals, which often convey emotions and attitudes more powerfully than words alone.

When documenting a resident's intake and output, the nurse aide should:

Answer: Record all fluid intake and urinary/other output accurately in milliliters

Accurate intake and output recording in measurable units is critical for monitoring hydration status and guiding medical decisions.

A nurse aide who disagrees with a care plan instruction should:

Answer: Follow the care plan and discuss concerns with the charge nurse

Nurse aides must follow established care plans while using proper channels—speaking with the charge nurse—to raise professional concerns.

Which statement about SBAR communication is MOST accurate for nurse aides?

Answer: SBAR stands for Situation, Background, Assessment, and Recommendation

SBAR is a structured communication tool that helps nurse aides organize and clearly convey information when reporting to the charge nurse.

A resident becomes agitated and starts yelling. The nurse aide's FIRST response should be:

Answer: Remain calm, speak softly, and try to identify the cause of the agitation

A calm, quiet tone de-escalates agitation and helps identify triggers, which is the foundation of safe therapeutic communication.

Which of the following demonstrates proper use of medical abbreviations in documentation?

Answer: Using only abbreviations approved by the facility's policies

Only facility-approved abbreviations should be used in documentation to ensure clarity, prevent errors, and meet legal standards.