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 C

Explanation

A. Dorsal surface of the foot:

The skin on the dorsal surface of the foot may have more pigmentation, making it potentially more challenging to detect cyanosis in individuals with dark skin.

B. Pinnae of the ears:

The ears may have variable pigmentation, and the presence of hair can affect the visibility of cyanosis. The skin on the pinnae may not be as thin as the skin on the dorsal surface of the hand.

C. Dorsal surface of the hand

When assessing for cyanosis in a client with dark skin, the nurse should examine areas with less pigmentation or areas where the skin is thin. The dorsal surface of the hand is often a suitable site, as it is less pigmented and can show bluish discoloration if cyanosis is present.

D. Conjunctivae:

The conjunctivae (the mucous membranes lining the inner surface of the eyelids and covering the white part of the eyes) are not a reliable site for assessing cyanosis in individuals with dark skin. Mucous membranes may not show cyanosis as prominently as the skin.

A. Mutually establish desired outcomes of the plan of care B. Guide selection of nursing interventions to meet expected outcomes C. Establish a database of information for future comparison D. Evaluate the effectiveness of the established plan of care

Correct Answer is B

Explanation

A. Mutually establish desired outcomes of the plan of care:

While establishing desired outcomes is an important part of the nursing process, nursing diagnoses themselves do not necessarily focus on mutually establishing these outcomes. Nursing diagnoses help identify health problems and needs, which then guide the development of outcomes during the planning phase.

B. Guide selection of nursing interventions to meet expected outcomes:

This is the correct answer. Nursing diagnoses help determine the specific needs and problems a patient is facing. Once identified, nursing interventions can be chosen to address these needs and work towards achieving expected outcomes.

C. Establish a database of information for future comparison:

Establishing a database of information is more related to the assessment phase of the nursing process. Nursing diagnoses are formulated based on the analysis of the collected data and serve to guide subsequent steps in the nursing process, particularly planning and intervention.

D. Evaluate the effectiveness of the established plan of care:

Evaluating the effectiveness of the established plan of care is part of the later stages of the nursing process. Nursing diagnoses help in planning and implementing interventions, and evaluating their effectiveness comes after these interventions have been carried out.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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