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 B
Explanation
The correct answer is choice b. I will need to remain upright for 1 hour after taking the medication.
Choice A rationale:
Pantoprazole can be taken with or without food, so it does not need to be taken on an empty stomach.
Choice B rationale:
Remaining upright for at least 1 hour after taking pantoprazole helps prevent acid reflux and ensures the medication works effectively.
Choice C rationale:
Diarrhea is a possible side effect of pantoprazole, but it is not an expected outcome for all patients. If diarrhea occurs, it should be reported to a healthcare provider.
Choice D rationale:
Antacids can be taken with pantoprazole, but it is generally recommended to take them at different times to avoid potential interactions.
Correct Answer is A
Explanation
Choice A reason:
Goal – oriented is the correct answer. Obsessive-compulsive personality disorder (OCPD) is a personality disorder characterized by a pattern of preoccupation with orderliness, perfectionism, and control. Individuals with OCPD tend to be highly organized, detail-oriented, and focused on achieving their goals. They often set strict standards for themselves and others and are driven by a strong need for perfection in all aspects of their lives.
Choice B reason
Provocative behaviour is not a characteristic commonly associated with obsessive-compulsive personality disorder (OCPD). In fact, individuals with OCPD tend to be more reserved, cautious, and serious in their interactions with others.
Choice C reason:
Lack of empathy While individuals with OCPD may struggle with interpersonal relationships due to their rigid standards and expectations, they typically do not lack empathy. They might find it challenging to understand and relate to emotions or perspectives that do not align with their own, but this is different from a complete lack of empathy, which is more commonly seen in certain other personality disorders
Choice D reason.
Lability refers to emotional instability or rapid and extreme shifts in emotions. This is not a typical feature of obsessive-compulsive personality disorder (OCPD). Individuals with OCPD tend to be emotionally restrained and might have difficulty expressing emotions, rather than experiencing emotional lability.
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