A nurse in the emergency department is caring for a client.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing

Exhibits

due to

dropdown

A. An occurrence report, also known as an incident report, documents the details of any unexpected event that occurs during the client's care. This includes falls. It is important to document the incident accurately and promptly in the client's medical record to ensure that all relevant information is recorded. However, this should not take priority over timely escalation of the issue.
B. It is essential to notify the client's healthcare provider (such as the physician or nurse practitioner) about the fall incident. The provider needs to be informed about the client's condition after the fall, any injuries sustained, and any immediate actions taken.
C. The nurse who witnessed or discovered the fall incident is responsible for completing the occurrence report. It should be filled out by the nurse who directly assessed the client's condition after the fall, documented any injuries, and initiated appropriate interventions. Asking another nurse to complete the report may not accurately reflect the details and actions taken by the nurse who was directly involved.
D. Risk management may need to be informed about the fall incident, especially if it resulted in injury to the client. Risk management is responsible for assessing the circumstances surrounding the fall, identifying potential risks or contributing factors, and implementing strategies to prevent future incidents. However, contacting risk management is typically done after initial actions such as ensuring client safety, notifying the provider, and documenting the incident.

A. An inguinal hernia typically does not directly contribute to an increased risk of falls. It is a condition where tissues, such as part of the intestine, protrude through a weak spot in the abdominal muscles. While it may require caution with certain movements or heavy lifting to prevent exacerbation, it is not typically associated with balance or mobility issues that would increase fall risk.
B. Hyperthyroidism is a condition where the thyroid gland produces excessive thyroid hormone. Symptoms may include nervousness, tremors, rapid heart rate (palpitations), and muscle weakness. While muscle weakness could potentially contribute to an increased fall risk, it's not typically a primary factor unless the weakness is severe or affecting lower extremity strength significantly.
C. Hyperlipidemia refers to elevated levels of lipids (fats) in the blood, such as cholesterol and triglycerides. While it is a risk factor for cardiovascular disease, it does not directly increase the risk of falls.
D. Multiple sclerosis (MS) is a neurological condition that can cause a wide range of symptoms, including muscle weakness, coordination problems, and balance issues. These neurological impairments significantly increase the risk of falls due to impaired mobility and balance control.