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.
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Related Questions
Correct Answer is D
Explanation
A. Move any clients in the immediate vicinity.
This is a reasonable next step, ensuring the safety of clients in close proximity to the potentially hazardous situation.
B. Close the fire doors on the unit.
Closing fire doors is important for containing the spread of smoke and fire, but it may be a secondary action after alerting others to the emergency using the fire alarm.
C. Use a fire extinguisher on the outlet.
While fire extinguishers can be useful in certain situations, using one on an electrical fire can be dangerous. It's generally recommended to leave firefighting to trained personnel and focus on evacuation and alerting others.
D. Activate the fire alarm.
Activating the fire alarm is the priority because it alerts everyone in the facility to the potential danger, ensuring a prompt and coordinated response. It initiates the facility's fire response plan and helps in the evacuation of patients if necessary.
Correct Answer is B
Explanation
A. Concurrent treatment for GERD:
This is not typically a contraindication for hormone replacement therapy (HRT). GERD treatment is not directly related to the decision to use HRT.
B. History of breast cancer:
This is a contraindication for HRT. Estrogen replacement therapy has been associated with an increased risk of breast cancer. Therefore, individuals with a history of breast cancer are generally advised against using HRT.
C. History of dermatitis:
A history of dermatitis is not a contraindication for HRT. However, the decision to use HRT should be made based on a comprehensive assessment of the client's overall health and risk factors.
D. Multiple hospitalizations for COPD:
While COPD itself is not a contraindication for HRT, decisions about HRT should consider the individual's overall health status and potential risks. Factors such as smoking history and respiratory function may be considered in the assessment.
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