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Nursing Documentation – Practice Questions for Clinical Accuracy and Record-Keeping Skills (Complete Practice Material)

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This set of Nursing Documentation practice questions covers core principles of accurate charting, legal requirements, and best practices in clinical record-keeping. It includes scenario-based questions that help students apply documentation standards in real healthcare settings. The material is suitable for exam preparation as well as practical skill reinforcement.

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1. The patient says, “I’m really worried about surgery tomorrow”; the nurse responds, “You’re worried about
surgery?” The nurse is using which of the following communication techniques?

a. reflecting
b. broad opening
c. paraphrasing
d. leading

2. The patient says, “I’m so scared being in the hospital.”; the nurse responds, “Don’t worry, you’ll be fine.”
Which of the following statements would be a better response?

a. “Why would you be scared?”
b. “There is nothing to be afraid of.”
c. “You seem upset, let’s talk about it.”
d. “Don’t be silly!”

3. The patient says, “I’ve had my light on for so long, and no one answers.” What would be an appropriate
response?

a. “I’m sorry, but I was taking care of someone else.”
b. “We are really busy today.”
c. “I’m doing the best I can.”
d. “I’m sorry, how can I help you?”

4. The patient says, “I just don’t know what to do, what would you do?” How should the nurse respond?

a. “If I were you, I would do what the doctor tells you.”
b. “I don’t know, talk with your doctor.”
c. “You seem unsure, would you like to talk about it?”
d. “It’s up to you.”

5. The patient says, “I know the biopsy will be positive.” What would be an appropriate response?

a. “Don’t worry!”
b. “Wait and see!”
c. “You seem concerned, what makes you feel that way?”
d. “No need to worry yet.”

6. The patient says, “I’ll never be able to give myself insulin.” What would be an appropriate response?

a. “Don’t worry, it just takes time.”
b. “This seems hard for you, let’s go over this again.”
c. “Kids can even do it.”
d. “Don’t be silly, it is easy.”



7. If all the following are discussed at a nursing conference, which one is most essential to promoting a
therapeutic nurse-client relationship.



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, a. getting to know the client’s family
b. carrying out the medical orders
c. treating each client as a unique person
d. calling the client by his or her first name.

8. If all the following techniques are explained at the conference, the best approach for encouraging a client to
elaborate verbally is to use a technique referred to as:

a. paraphrasing
b. confronting
c. giving general leads
d. open ended questions

9. Upon returning to the nursing unit after the conference a nurse explains to the other personnel that even
agreeing with the client is considered a non-therapeutic communication technique because it

a. inhibits clients from changing their minds
b. discouraging independent problem-solving
c. alters the direction of the discussion
d. treats clients in a condescending manner

10. A nursing assistant reports to the practical nurse that the preoperative client scheduled for removal of a
cancerous breast is quiet and non-communicative. Which comment by the nurse is most accurate

a. this is the way most clients indicate they do not wish to talk about a subject
b. it may not be necessary to probe a little for more information on how the client feels
c. silence does not always indicate that a client is feeling secure
d. assume that the client feels more comfortable communicating nonverbally

11. Which one of the following would be the best assessment for determining if a client is experiencing
anxiety.

a. skin temperature
b. bowel sounds
c. heart rate
d. urine output

12. The two types of communication behaviors are:

a. judgmental and nonjudgmental
b. verbal and nonverbal
c. democratic and autocratic
d. explanation and persuasion

13. Body position, facial expression, gestures, moaning, crying, laughing, and smiling are examples of.

a. verbal communication
b. active communication
c. passive communication
d. nonverbal communication



14. Two essential parts of communication are:




2
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https://www.coursehero.com/file/67801353/Documentation-Practice-Questionsdoc/

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