A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
Notify the client's provider.
Measure the client's vital signs.
Complete an incident report.
Document the fall in the client's medical record.
The Correct Answer is B
When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. This assessment helps determine if there are any immediate medical concerns resulting from the fall, such as injury or shock, that require prompt attention.
The other options listed are also important but should be addressed after the initial assessment and safety measures:
A. Notify the client's provider: After assessing the client's condition, if there are significant injuries or concerns identified, the nurse should promptly notify the client's provider to seek further medical guidance and intervention.
C. Complete an incident report: Reporting the fall incident is an essential part of ensuring quality and safety in healthcare. However, it is not the first action the nurse should take. The immediate focus should be on the client's assessment and safety. Completing an incident report can be done once the client's immediate needs are addressed.
D. Document the fall in the client's medical record: Documenting the fall in the client's medical record is important for maintaining accurate and comprehensive documentation. However, it should be done after the client's assessment, vital sign measurement, and any necessary interventions have been carried out.
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Related Questions
Correct Answer is C
Explanation
Dependent personality disorder is characterized by an excessive reliance on others for decision-making and a fear of being alone or taking responsibility. Encouraging the client to be assertive helps promote their independence and self-confidence. It allows them to express their needs and preferences, make decisions, and take responsibility for their own actions.
Empowering the client to be assertive can enhance their overall well-being and promote healthier relationships.
A. Limiting the client's social interactions may exacerbate their dependency and hinder their progress in developing more self-reliance and independent coping skills. It is important to encourage appropriate and healthy social interactions while also promoting the client's independence.
B. Maintaining a verbal no-harm contract with the client is a strategy more commonly used for clients at risk of self-harm or harm to others. It may not be directly applicable to the care of a client with dependent personality disorder unless there are specific safety concerns.
D. Assuming responsibility for making the client's decisions would reinforce their dependency and enable their avoidance of taking personal responsibility. It is important to promote autonomy and support the client in making their own decisions whenever possible.
Correct Answer is B
Explanation
By using short, simple sentences, the nurse can effectively communicate with the client who is exhibiting signs of agitation and anxiety. This communication style can help reduce stress and confusion for the client and promote understanding.
A. Asking the client if they would like to watch television: While providing options for activities can be beneficial, it is important to address the client's current state of agitation and anxiety before suggesting any specific activities.
C. Allowing the client to have 1 hour of time alone in their room: While some clients may prefer solitude, in this case, the client's pacing and hand-wringing indicate signs of distress and may require therapeutic interventions rather than isolation.
D. Moving the client to a table where other clients are playing cards: This option may not address the client's current state of anxiety and pacing. Placing the client in a social setting with other clients might increase their distress and agitation.
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