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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Calf swelling is a sign of deep vein thrombosis, which is a blood clot that forms in a deep vein, usually in the lower leg or thigh. The clot can block the blood flow and cause inflammation, pain, and edema. The nurse should measure the circumference of both calves and compare them for any difference. The nurse should also report any other signs of deep vein thrombosis, such as warmth, redness, or tenderness.
Choice B reason: Clammy skin is not a sign of deep vein thrombosis, but of shock. Shock is a life-threatening condition that occurs when the body's organs do not receive enough blood and oxygen. The nurse should monitor the client's vital signs, such as blood pressure, pulse, and temperature, and report any abnormal findings.
Choice C reason: Tortuous veins are not a sign of deep vein thrombosis, but of varicose veins. Varicose veins are enlarged and twisted veins that appear near the surface of the skin, usually in the legs. They are caused by weak or damaged valves that allow blood to pool and stretch the veins. The nurse should assess the client's skin for any ulcers, bleeding, or infection.
Choice D reason: Bradycardia is not a sign of deep vein thrombosis, but of a slow heart rate. Bradycardia is a condition that occurs when the heart beats less than 60 times per minute. It can be caused by various factors, such as medication, heart disease, or hypothyroidism. The nurse should check the client's pulse and rhythm, and report any irregularities.
Correct Answer is D
Explanation
Choice A reason: Turning on loud music in client care areas is not a good action. Loud music can increase noise levels, disrupt sleep, and cause agitation and anxiety for clients. The nurse should keep the noise level low and provide earplugs or headphones for clients who want to listen to music.
Choice B reason: Assigning different nurses to provide care for clients each day is not a good action. Different nurses may have different styles, routines, and expectations, which can confuse and frustrate clients. The nurse should maintain consistency and continuity of care by assigning the same nurses to the same clients as much as possible.
Choice C reason: While offering some choices can empower clients and reduce stress, too many choices might overwhelm them, particularly in an acute care setting. The key is to provide a balance of autonomy while not overwhelming the client.
Choice D reason: Limiting the number of visitors can help create a quieter, more controlled environment, reducing overstimulation and stress for clients. This can be particularly important in an acute care setting where rest and a calm environment are crucial for recovery.
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