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
Choice A reason:
Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.
Choice B reason:
Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.
Choice C reason:
Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.
Choice D reason:
The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.
Correct Answer is D
Explanation
Choice A reason:
Being honest with the parents of a child about the need to report suspected abuse is not the correct option. This option involves honesty and ethical responsibility but does not pertain to the fair distribution of resources or benefits.
Choice B reason
Keeping a promise to visit with a client who is housebound after the delivery of care is not the appropriate option. While keeping promises is an ethical principle, it is not related to the fair distribution of resources or benefits.
Choice C reason:
Accepting the decision of an older adult client to live alone in her home is not the correct option. Respecting a client's autonomy and right to make decisions about their living arrangements is an ethical principle, but it is not directly related to distributive justice.
Choice D reason:
The ethical principle of distributive justice is about fair and equitable distribution of resources and benefits within a society or group. It emphasizes providing equal access to services and resources to all individuals, especially those who are vulnerable or marginalized. In this context, the nurse demonstrates distributive justice by ensuring that a homeless client receives preventive medical care, which means they are being provided with necessary health resources and services that might otherwise be challenging for them to access due to their disadvantaged situation.
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