Communication and Documentation Flashcards
6 cards from real NACE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Communication and Documentation flashcards as text
A patient says, 'I feel like no one really listens to me.' Which nurse response demonstrates the best therapeutic communication technique?
Answer: 'Tell me more about what you mean by that.'
Open-ended statements like 'Tell me more' encourage the patient to elaborate and show genuine interest. Reassuring ('don't worry') or minimizing responses block communication. Redirecting to another nurse dismisses the patient's concern.
A nurse needs to hand off a patient to the oncoming nurse. Which communication framework is the standard for structured handoff reporting?
Answer: SBAR
SBAR (Situation, Background, Assessment, Recommendation) is the standardized handoff communication tool used to provide concise, organized information during patient transfers and shift changes, reducing communication errors.
A nurse discovers a medication error was made by a previous nurse. Which documentation action is correct?
Answer: Document the error in the patient's chart and file an incident report
Medication errors must be documented in the patient's chart (objective facts only—what happened and patient's response) and reported via an incident/occurrence report. Altering another's documentation is falsification; omitting it from the chart is incomplete documentation.
Which of the following is an example of a nonverbal communication barrier that a nurse should be aware of?
Answer: Standing over a seated patient while delivering bad news
Standing over a seated patient creates a power imbalance and communicates dominance rather than partnership—this is a nonverbal barrier. The other options are verbal communication issues. Sitting at eye level with a patient during sensitive conversations conveys respect and openness.
A nurse is documenting assessment findings. Which entry is written correctly?
Answer: 'Patient rates pain 7/10, diaphoretic, guarding abdomen, BP 152/94.'
Nursing documentation must be objective, specific, and measurable. Option C uses a numeric pain scale, observable signs (diaphoresis, guarding), and a vital sign—all objective data. The other options contain subjective interpretation ('seemed,' 'probably,' 'uncooperative') which are inappropriate in clinical documentation.
A patient who speaks limited English is scheduled for surgery. The nurse needs to obtain informed consent. What is the most appropriate action?
Answer: Use a hospital-approved professional medical interpreter
A professional medical interpreter (in person or via phone/video service) must be used for informed consent to ensure accurate communication and protect patient rights. Using family members is discouraged due to potential bias, omissions, or distortion. This is also a legal and accreditation requirement.