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."

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Answer: D. Abnormal Involuntary Movement Scale

Rationale: The Abnormal Involuntary Movement Scale is a diagnostic tool that assesses the severity of tardive dyskinesia, a disorder that results in involuntary repetitive body movements caused by long-term use of antipsychotic drugs.

A. "Let me demonstrate for you how to use this machine correctly." B. "Tell me how long you have been using this glucometer." C. "Show me what blood glucose supplies you have available." D. "I would like to observe you using your glucometer."

Correct Answer is D

Explanation

The nurse should observe the client using the glucometer to assess their technique and accuracy. This is an example of a return demonstration, which is an effective teaching method for psychomotor skills.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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