A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record?
"Client fell out of bed and cut his forehead due to sedative-induced confusion."
"Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."
"Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."
"Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in medical record for further details."
The Correct Answer is C
A. "Client fell out of bed and cut his forehead due to sedative-induced confusion."
This option provides information about the fall and the cause but lacks specific details about the injury, location, or the client's orientation. It is not as detailed or objective as it could be.
B. "Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."
This option includes information about the client's position, the presence of blood, and attributes the fall to the failure of the assistive personnel to put up side rails. While it provides some details, it introduces an element of blame and speculation. It's important to stick to factual information in documentation.
C. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."
This option provides specific details about the client's position, the nature and location of the injury (laceration), and the client's orientation status. It is concise, objective, and focused on the relevant information.
D. "Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in the medical record for further details."
This option includes information about the fall, the injury, and refers to an incident report for further details. While it provides information, it may be more appropriate to include essential details directly in the documentation rather than referring to another document for additional information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Position the client on her side:
While placing the client on her side is important, especially if there is a risk of aspiration during the seizure, maintaining the airway takes precedence as the priority action.
B. Maintain the patency of the client's airway:
This is the correct answer. Ensuring the airway is open and unobstructed is the immediate priority during a seizure. This involves positioning the client to prevent airway compromise and potentially using suction if necessary.
C. Identify the poison the client ingested:
While identifying the poison is important for subsequent management, it is not the immediate priority during an active seizure. The focus is on stabilizing and ensuring the client's safety.
D. Measure the client's blood pressure:
Monitoring vital signs, including blood pressure, is an essential aspect of care, but it is not the immediate priority during an active seizure. Airway management takes precedence to prevent complications such as hypoxia.
Correct Answer is ["D","E"]
Explanation
A. Place the child in prone position:
Placing the child in a prone position (lying face down) during a seizure can obstruct the airway and lead to potential breathing difficulties.
B. Restrain the child:
Restraining a child during a seizure can cause injury or increase agitation. It's important to allow the child to move safely and avoid trying to hold them down.
C. Place a tongue depressor in the child's mouth:
It is not recommended to place anything, including a tongue depressor, in the child's mouth during a seizure. Doing so can cause injury to the child's teeth or oral structures.
D. Clear the area of hard objects:
Removing hard or sharp objects from the vicinity helps prevent injury to the child during the seizure.
E. Loosen restrictive clothing:
Loosening any tight clothing, especially around the neck, chest, or waist, allows the child to breathe more easily and reduces potential constriction during the seizure.
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