A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
The client fell because the assistive personnel did not place nonskid slippers on the client."
The client does not appear to have any injuries resulting from the fall."
"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'."
"An incident report has been completed and sent to risk management."
The Correct Answer is C
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client has a decreased energy level.A decreased energy level can be a common symptom of many conditions, including terminal illnesses. While it can be associated with feelings of hopelessness, it is not necessarily an indication of it. Other factors like the illness itself, treatments, or emotional stress can contribute to low energy.
B. The client requests a second opinion.Requesting a second opinion is generally a sign that the client is still actively engaged in their care and is seeking more information or alternative options. It indicates hope or a desire for different possibilities rather than hopelessness.
C. The client wants to talk about the diagnosis with the nursing staff.Wanting to talk about the diagnosis with the nursing staff suggests that the client is processing the information and seeking support. Open communication is a positive coping mechanism and not typically an indication of hopelessness.
D. The client makes funeral arrangements.When a client makes funeral arrangements, it can be a sign that they are feeling hopeless about their situation and are preparing for the end of their life. While it is practical and sometimes necessary to make such arrangements, in this context, it can be seen as a manifestation of hopelessness.
Correct Answer is B
Explanation
Choice A reason
While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.
Choice B reason.
Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure
Choice C reason:
While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.
Choice D reason:
Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.
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