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."

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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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.

A. A 15-year old client who has acne B. A client who has a menstrual cycle every 14 days C. A client who has a blood pressure of 140/90 mm Hg D. A client who has a hematocrit of 39%

Correct Answer is C

Explanation

A. A 15-year-old client who has acne:

Acne alone is not a contraindication to oral contraceptives. In fact, oral contraceptives can sometimes be prescribed to help manage acne.

B. A client who has a menstrual cycle every 14 days:

Having a menstrual cycle every 14 days may indicate an irregular cycle, but it's not a direct contraindication to oral contraceptives. However, the cause of the frequent cycles might need evaluation before starting oral contraceptives.

C. A client who has a blood pressure of 140/90 mm Hg:

Elevated blood pressure (140/90 mm Hg or higher) is a contraindication to oral contraceptives. It increases the risk of complications such as stroke, heart attack, or other cardiovascular issues.

D. A client who has a hematocrit of 39%:

A hematocrit level of 39% is within the normal range and is not a contraindication to oral contraceptives.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients as having a contraindication to oral contraceptives?

Correct Answer is C

Explanation

A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

A nurse is caring for an older adult client who has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?

As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

A nurse is caring for a group of clients on a medical surgical unit. Which of the following tasks is unsafe to assign to an assistive personnel (AP)?

A nurse is reviewing a client's medication administration record. For which of the following medications should the nurse place the client on fall precautions?

A nurse is caring for a client who is experiencing menopausal symptoms and requests information about hormone replacement therapy (HRT). Which of the following items in the client's health history is a contraindication for hormone replacement therapy?

A float nurse is given a client assignment that requires the use of unfamiliar skills and techniques. Which of the following actions should the nurse take?