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 ["A","B","C","E"]

Explanation

A. Placing the bedside table within the client's reach helps to minimize the need for the older adult to reach or stretch, reducing the risk of falls.

B. Keeping the bed at a comfortable working height makes it easier for the older adult to get in and out of bed safely.

C. Keeping a night light on in the client's room and bathroom helps improve visibility during the night, reducing the risk of tripping or falling.

D. Administering a sedative at bedtime is generally not recommended as a preventive measure for falls. Sedatives can increase the risk of drowsiness and impaired balance, contributing to falls.

E. Locking the wheels on beds and wheelchairs during transfers helps ensure stability and prevents the equipment from moving unexpectedly, reducing the risk of falls during transfers.

A. A client who has had prolonged diarrhea B. A client who has lactose intolerance C. A client who has had radiation therapy for head and neck cancer D. A client who has had a stroke E. A client who is 4 hr postoperative following a leg amputation under general anesthesia

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

Explanation

A. A client who has had prolonged diarrhea:

Prolonged diarrhea is not typically associated with an increased risk of aspiration during eating.

B. A client who has lactose intolerance:

Lactose intolerance primarily affects the ability to digest lactose-containing foods and does not directly increase the risk of aspiration.

C. A client who has had radiation therapy for head and neck cancer:

Radiation therapy to the head and neck can cause damage to the structures involved in swallowing, increasing the risk of aspiration.

D. A client who has had a stroke:

Stroke can affect the coordination of swallowing muscles, leading to dysphagia (difficulty swallowing) and an increased risk of aspiration.

E. A client who is 4 hr postoperative following a leg amputation under general anesthesia:

Postoperative clients under general anesthesia may experience impaired protective airway reflexes, making them prone to aspiration. It's important to monitor these clients closely during the initial recovery period.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk for aspiration while eating? (Select all that apply.)

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

Explanation

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 caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

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?

A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

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?

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A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?