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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is b. Misunderstanding of roles.
Choice A: Scope of practice
Reason: While the scope of practice defines the roles and responsibilities of different healthcare professionals, it is not inherently a barrier to interprofessional communication. Instead, it provides clarity on what each professional can and cannot do, which can actually facilitate better teamwork and communication.
Choice B: Misunderstanding of roles
Reason: Misunderstanding of roles is a significant barrier to interprofessional communication. When team members are unclear about each other’s roles and responsibilities, it can lead to confusion, overlap, and gaps in care. This misunderstanding can hinder effective collaboration and communication, as team members may not know who to turn to for specific issues or may duplicate efforts.
Choice C: Privacy laws
Reason: Privacy laws, such as HIPAA in the United States, are designed to protect patient information. While they impose certain restrictions on information sharing, they are not a primary barrier to interprofessional communication. Healthcare teams can still communicate effectively within the boundaries of these laws by ensuring that patient information is shared appropriately and securely.
Choice D: Burnout
Reason: Burnout is a significant issue in healthcare, affecting the well-being and performance of healthcare professionals. However, it is more of a personal and systemic issue rather than a direct barrier to interprofessional communication. Burnout can indirectly affect communication by reducing the overall effectiveness and engagement of team members.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because psychiatric history is not the most urgent assessment to make for a client who reports feeling depressed and anxious. Psychiatric history can provide valuable information about the client's diagnosis, treatment, and response, but it is not a priority over the client's safety and wellbeing.
Choice B reason: This statement is correct because suicide risk is the most urgent assessment to make for a client who reports feeling depressed and anxious. Suicide risk can indicate the client's level of hopelessness, despair, and intent to harm themselves. The nurse should assess the client's suicidal thoughts, plans, means, and access, and implement appropriate interventions to prevent self harm or suicide.
Choice C reason: This statement is incorrect because support systems are not the most urgent assessment to make for a client who reports feeling depressed and anxious. Support systems can provide emotional, social, and practical assistance to the client, but they are not a priority over the client's safety and wellbeing.
Choice D reason: This statement is incorrect because coping abilities are not the most urgent assessment to make for a client who reports feeling depressed and anxious. Coping abilities can reflect the client's strategies and skills to manage their stress and emotions, but they are not a priority over the client's safety and wellbeing.
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