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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Improved speech patterns:
While selegiline may contribute to overall improvement in motor function and quality of life for individuals with Parkinson's disease, it is not specifically known for targeting speech patterns.
B. Decreased tremors:
This is the correct therapeutic outcome. Selegiline is a monoamine oxidase type B (MAO-B) inhibitor that helps increase dopamine levels in the brain. Reduction of tremors is a common therapeutic effect in Parkinson's disease.
C. Increased bladder function:
Selegiline primarily affects motor symptoms in Parkinson's disease and is not directly associated with changes in bladder function.
D. Diminished drooling:
While drooling can be a symptom of Parkinson's disease, selegiline's primary focus is on motor symptoms, and its impact on drooling may be variable. Other interventions may be considered for managing drooling in Parkinson's disease.
Correct Answer is B
Explanation
A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.
B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.
C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.
D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.
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