A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

Choice A reason: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.

Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.

Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.

Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.

Choice A reason: Diminished hand-to-mouth coordination is not a finding that requires a referral to speech-language pathology, as it is related to the motor function of the upper extremities. The nurse should refer the client to physical therapy or occupational therapy for this issue.

Choice B reason: Impaired voluntary cough is a finding that requires a referral to speech-language pathology, as it indicates a possible dysfunction of the swallowing mechanism or the vocal cords. The nurse should refer the client to speech-language pathology for a swallowing evaluation and intervention.

Choice C reason: Altered level of consciousness is not a finding that requires a referral to speech-language pathology, as it is related to the neurological function of the brain. The nurse should monitor the client's Glasgow Coma Scale score and report any changes to the provider.

Choice D reason: Unilateral ptosis is not a finding that requires a referral to speech-language pathology, as it is related to the cranial nerve function of the eye. The nurse should assess the client's pupillary response and eye movements and report any abnormalities to the provider.