A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
A client reports being dissatisfied with the temperature of the meals provided.
A client receives burns from a heating pad.
A client becomes disoriented and falls out of bed.
A client is unable to afford the physical therapy that the provider recommends.
A client's visitor's getting dizzy and fainting in the client's room
Correct Answer : B,C,E
Choice A reason: A client's dissatisfaction with the temperature of the meals is not an incident that requires a report. The nurse should inform the dietary staff and try to accommodate the client's preferences.
Choice B reason: A client's burns from a heating pad is an incident that requires a report. The nurse should document the cause, extent, and treatment of the burns, as well as the client's response and any actions taken to prevent recurrence.
Choice C reason: A client's disorientation and fall out of bed is an incident that requires a report. The nurse should document the circumstances, injuries, and interventions related to the fall, as well as the client's response and any changes in the plan of care.
Choice D reason: A client's inability to afford the physical therapy is not an incident that requires a report. The nurse should refer the client to a social worker or a financial counselor who can assist with finding resources and options.
Choice E reason: A client's visitor's dizziness and fainting in the client's room is an incident that requires a report. The nurse should document the event, the visitor's condition, and any actions taken to assist the visitor.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Talking at a rapid rate is not a good action to promote communication with a client who has hearing loss. Talking too fast can make it harder for the client to follow the conversation, lip-read, or use hearing aids. The nurse should talk at a normal rate and pause between sentences.
Choice B reason: Using short phrases is not a good action to promote communication with a client who has hearing loss. Using short phrases can make the message unclear, incomplete, or condescending. The nurse should use complete sentences and avoid jargon, slang, or abbreviations.
Choice C reason: Decreasing background noise is a good action to promote communication with a client who has hearing loss. Background noise can interfere with the client's ability to hear and understand the nurse. The nurse should reduce or eliminate any sources of noise, such as TV, radio, or other people, and choose a quiet and well-lit place to talk.
Choice D reason: Speaking in a loud voice is not a good action to promote communication with a client who has hearing loss. Speaking too loud can distort the sound, cause discomfort, or offend the client. The nurse should speak in a clear and natural voice and adjust the volume according to the client's feedback.
Correct Answer is A
Explanation
Choice A reason: Receiving emotional support during the mother’s illness is a sign of understanding the teaching. Palliative care is a holistic approach that aims to improve the quality of life of clients and their families who are facing life-threatening illnesses. It provides physical, psychological, social, and spiritual support to address their needs and preferences.
Choice B reason: Providing resuscitation to the mother if necessary is a sign of misunderstanding the teaching. Palliative care focuses on relieving symptoms and suffering, not curing the illness or prolonging life. It respects the client’s wishes and goals of care, which may include a do-not-resuscitate (DNR) order or an advance directive.
Choice C reason: Not discussing the illness in the presence of the mother is a sign of misunderstanding the teaching. Palliative care encourages open and honest communication between the client and the family, as well as the health care team. It helps the client and the family cope with the illness, express their emotions and concerns, and make informed decisions.
Choice D reason: Not allowing the mother’s spiritual advisor to visit during this time is a sign of misunderstanding the teaching. Palliative care recognizes the importance of spirituality and religion for some clients and their families. It supports the client’s right to practice their faith and receive spiritual guidance and comfort from their chosen source.
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