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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Related Questions
Correct Answer is C
Explanation
Choice A reason: You do not need to have advance directives in place in order to refuse recommended treatment. Advance directives are legal documents that allow you to express your wishes for your health care in case you are unable to communicate or make decisions for yourself. You have the right to accept or refuse any treatment at any time, as long as you are competent and informed.
Choice B reason: An attorney is not needed in order for you to name a designee in your health care proxy. A health care proxy is a type of advance directive that allows you to appoint a person to make health care decisions for you if you are unable to do so. You can choose anyone you trust, such as a family member or a friend, as your designee. You do not need a lawyer to complete a health care proxy form, but you need to sign it in front of two witnesses.
Choice C reason: You can decline to have certain medical procedures performed in your living will. A living will is another type of advance directive that allows you to state your preferences for life-sustaining treatments, such as CPR, artificial ventilation, or feeding tubes. You can specify which treatments you want or do not want, and under what circumstances. You can also include your values and beliefs about your quality of life and end-of-life care.
Choice D reason: A living will cannot be an oral statement that you agree upon with your provider. A living will must be a written document that is signed by you and witnessed by two people. An oral statement may not be legally valid or enforceable, and it may not reflect your current wishes. You should review and update your living will periodically, and share it with your provider, your designee, and your family.
Correct Answer is D
Explanation
Choice Areason: Removing the wheels from rolling chairs is a good practice to prevent the chairs from sliding or moving unexpectedly. It is not a risk factor for falls, but rather a safety measure to prevent them.
Choice Breason: A stool riser is a device that elevates the toilet seat and makes it easier for the client to sit down and stand up. It is not a risk factor for falls, but rather a safety measure to prevent them.
Choice C reason: Having the mattress directly on the floor may make it harder for the client to get in and out of bed, but it does not increase the risk of falls. In fact, it may reduce the risk of injury if the client falls from the bed, as the height is lower.
Choice D reason: Covering electrical cords with throw rugs is a risk factor for falls, as the client may trip over them or get tangled in them. It is also a fire hazard, as the rugs may overheat or catch fire from the cords. The nurse should advise the client to remove the rugs and secure the cords away from the walking areas.
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