A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

A. "Establish a daily exercise routine." Regular physical activity helps regulate the sleep-wake cycle and promotes deeper sleep. Exercising earlier in the day enhances sleep quality, but vigorous exercise close to bedtime should be avoided as it can be stimulating.
B. "Keep the television volume low while you are trying to fall asleep." Watching television before bed can interfere with melatonin production due to blue light exposure, making it harder to fall asleep. A dark, quiet environment is recommended for better sleep.
C. "Remain in bed until you fall asleep." Staying in bed while struggling to sleep can reinforce insomnia. It is recommended to get out of bed and engage in a relaxing activity if unable to sleep within 20 minutes, then return when drowsy.
D. "Sleep longer hours on the weekend." Sleeping in on weekends disrupts the body's internal clock and can worsen sleep difficulties. Maintaining a consistent sleep schedule, even on weekends, helps regulate circadian rhythms and improve sleep quality.

A. Completing an incident report is required for tracking falls and improving safety measures, but it is not the first priority. The nurse must first assess the client to determine if immediate medical intervention is needed. Delay in assessment could lead to unrecognized injuries or complications. Incident reports are also not part of the medical record and should be completed after client care. Ensuring client stability always takes precedence over documentation.
B. Measuring vital signs is the priority because it helps identify any immediate complications from the fall, such as hypotension, pain, or neurological impairment. A sudden drop in blood pressure could indicate shock, while tachycardia may suggest distress or injury. Checking for changes in mental status, pain levels, and potential fractures ensures timely intervention. If abnormalities are found, further evaluation or treatment can be initiated promptly. Early assessment prevents worsening conditions and guides further actions.
C. Documenting the fall in the client's medical record is necessary for continuity of care but should be done after assessing and stabilizing the client. Medical documentation includes details about the fall, findings from the assessment, and any interventions provided. However, delaying assessment to document first could result in missed critical signs of injury. Proper documentation supports quality care but is secondary to ensuring the client’s immediate well-being. The nurse should prioritize physical assessment before recording the incident.
D. Notifying the provider is important, especially if the client has sustained injuries, is in pain, or has abnormal vital signs. However, calling the provider before performing an assessment can lead to incomplete or inaccurate reporting. The provider will need specific details about the client's condition, including neurological status, hemodynamics, and any visible injuries. Conducting an assessment first ensures that the provider receives the most relevant and useful information. Immediate assessment allows for timely intervention and prevents unnecessary delays in care.