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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?

A.

"Client fell out of bed and cut his forehead due to sedative-induced confusion."

B.

"Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."

C.

"Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."

D.

"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."

Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

A. "I'm sure your wife will begin to feel better soon."

This response is somewhat reassuring but may come across as dismissive or overly optimistic. It doesn't acknowledge the partner's feelings or offer support.

B. "It must be very difficult for you to see your wife in pain."

This response acknowledges the partner's emotions and shows empathy. While it recognizes the difficulty the partner is experiencing, it doesn't directly address the partner's desire to do something to help the wife.

C. "I wish there was more that I could do to relieve your wife's pain, too."

This response directly empathizes with the partner's wish to help the wife, expressing a shared concern. It conveys a sense of teamwork between the nurse and the partner, fostering a supportive connection.

D. "We're doing everything we can to keep your wife comfortable."

This response provides information about the actions being taken by the medical team but may not directly address the partner's expressed desire to contribute or alleviate the wife's pain.

Correct Answer is D

Explanation

A. "Unlike an x-ray, the MRI allows you to move around a bit":

This statement is not accurate. During an MRI, it is important for the client to remain as still as possible to obtain clear images. Movement can result in blurred images.

B. "Your exposure to radiation will be minimal":

This statement is not applicable to MRI, as MRI does not use ionizing radiation. It uses a strong magnetic field and radio waves to generate images, making it different from x-rays in terms of radiation exposure.

C. "You will not be able to talk to the technician during the procedure":

While it is essential for the client to remain still during an MRI, communication with the technician is generally possible through an intercom system. The client may be given instructions and reassurance during the procedure.

D. "You'll have to remove metal objects such as watches and body jewelry":

This is the correct statement. Metal objects can interfere with the magnetic field used in MRI and can pose a safety risk. Therefore, clients are required to remove any metal objects before undergoing an MRI.

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