A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

The client attempted to climb over the side rails and fell

The client was restless and trying to get out of bed all evening

The presence of a bed alarm could have prevented the client from falling

The client was lying on the floor next to his bed

Answer and Explanation

The Correct Answer is D

A. The client attempted to climb over the side rails and fell:

This statement includes an interpretation of the client's actions. It's important to focus on factual information without making assumptions about the client's intentions or actions.

B. The client was restless and trying to get out of bed all evening:

Describing the client as restless and trying to get out of bed is a subjective interpretation of the client's behavior. Factual and objective observations are preferred when documenting incidents.

C. The presence of a bed alarm could have prevented the client from falling:

This statement includes an interpretation and a suggestion for prevention. While prevention strategies are important to consider, an incident report should primarily focus on describing what actually occurred rather than suggesting what could have prevented it.

D. The client was lying on the floor next to his bed:

This statement provides a clear and objective description of the situation without making assumptions or interpretations. It is important to document the actual events and the client's current condition.

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Correct Answer is D

Explanation

A. Develop a plan of care for the client:

Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.

B. Provide a schedule of visiting hours to the client’s family:

While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.

C. Teach the client about his diagnosis:

Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.

D. Document the client’s code status

When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.

Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.

A. Ask the client if she is having pain B. Request a prescription for an antianxiety medication C. Request a prescription for an antihypertensive medication D. Return in 30 min to recheck the client’s blood pressure

Correct Answer is A

Explanation

A. Ask the client if she is having pain.

This option recognizes the potential relationship between pain and elevated blood pressure. Assessing the client for pain is crucial, as pain can contribute to increased blood pressure.

B. Request a prescription for an antianxiety medication.

This option assumes that anxiety might be the cause of the elevated blood pressure. However, without further assessment, it may not be appropriate to jump to prescribing medication for anxiety.

C. Request a prescription for an antihypertensive medication.

Initiating antihypertensive medication without further assessment may not be the most appropriate first step, especially if the elevated blood pressure is related to pain or another temporary factor.

D. Return in 30 minutes to recheck the client’s blood pressure.

While monitoring blood pressure is important, waiting 30 minutes without further assessment or intervention might delay addressing the underlying issue, especially if it is related to pain or another acute problem.

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A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

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