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 D
Explanation
Choice A reason: Increased convex curve of the cervical spine is not an indication of scoliosis, but of kyphosis. Kyphosis is a condition that causes a forward rounding of the upper back, resulting in a hunched posture.
Choice B reason: Increased concave curve of the thoracic spine is not an indication of scoliosis, but of lordosis. Lordosis is a condition that causes an excessive inward curvature of the lower back, resulting in a swayback posture.
Choice C reason: Expansion of the upper intercostal spaces is not an indication of scoliosis, but of emphysema. Emphysema is a lung disease that causes the air sacs to become damaged and enlarged, resulting in difficulty breathing and a barrel chest.
Choice D reason: Unequal height of the shoulders is an indication of scoliosis. Scoliosis is a condition that causes a sideways curvature of the spine, resulting in an asymmetrical appearance of the shoulders, hips, and waist.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because the client should urinate before the specimen collection to avoid contaminating the stool with urine.
Choice B reason: This is incorrect because the specimen should be kept in a cool area to prevent bacterial growth and decomposition.
Choice C reason: This is incorrect because the client should place at least 2.5 cm (1 in) of formed stool or 15 to 30 mL of liquid stool into a culture tube.
Choice D reason: This is correct because the client should avoid placing toilet tissue in the bedpan after defecation to prevent interfering with the laboratory analysis of the stool.
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