A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?
Use objective terminology when documenting
Wait at least 12 hours to report the occurrence
Omit the name of the individuals involved
Document completion of the report in the client’s medical record
The Correct Answer is A
Choice A reason: This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
Choice B reason: This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
Choice C reason: This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
Choice D reason: This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is false and should not be included in the teaching. Increase in saliva production does not increase the risk for dehydration, but rather helps to moisten the mouth and facilitate swallowing and digestion. Saliva production may decrease with aging due to factors such as medication side effects, dry mouth, or reduced fluid intake.
Choice B reason: This statement is false and should not be included in the teaching. Decrease in systolic blood pressure does not increase the risk for dehydration, but rather indicates a lower force of blood against the artery walls. Systolic blood pressure may decrease with aging due to factors such as reduced cardiac output, decreased vascular resistance, or orthostatic hypotension.
Choice C reason: This statement is true and should be included in the teaching. Decrease in kidney function increases the risk for dehydration, as it reduces the ability of the kidneys to concentrate urine and conserve water. Kidney function may decrease with aging due to factors such as reduced blood flow, decreased glomerular filtration rate, or loss of nephrons.
Choice D reason: This statement is false and should not be included in the teaching. Increase in percentage of body water does not increase the risk for dehydration, but rather indicates a higher proportion of water in relation to body weight. Percentage of body water may decrease with aging due to factors such as loss of muscle mass, increased fat tissue, or hormonal changes.
Correct Answer is A
Explanation
Choice A reason: Sunbathing is a modifiable risk factor for developing a disease. Sunbathing exposes the skin to ultraviolet (UV) radiation, which can damage the DNA and cause skin cancer. Sunbathing can also cause premature aging, sunburn, and eye damage. The nurse should advise the client to limit sun exposure, use sunscreen, wear protective clothing, and avoid tanning beds.
Choice B reason: Family history is not a modifiable risk factor for developing a disease. Family history refers to the inherited traits and diseases that occur in the family. Family history can increase the risk of developing certain diseases, such as diabetes, heart disease, and cancer. The nurse should assess the client's family history and provide genetic counseling if needed.
Choice C reason: Genetics is not a modifiable risk factor for developing a disease. Genetics refers to the genes that determine the characteristics and functions of the body. Genetics can influence the susceptibility and resistance to certain diseases, such as cystic fibrosis, sickle cell anemia, and hemophilia. The nurse should educate the client about the role of genetics in health and disease, and refer the client to a genetic specialist if needed.
Choice D reason: Age is not a modifiable risk factor for developing a disease. Age refers to the number of years that a person has lived. Age can affect the body's ability to fight infections, heal wounds, and prevent chronic diseases. The nurse should monitor the client's age-related changes and provide age-appropriate care and interventions.
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