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
Choice A reason: This statement does not demonstrate health literacy by the client, but rather a need for more health education. Health literacy is the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Requesting further information to improve their health indicates that the client may lack some knowledge or skills related to their condition.
Choice B reason: This statement demonstrates health literacy by the client, as it shows that they have learned and applied an important selfcare behavior for diabetes management. Taking blood glucose daily is a way to monitor and control blood sugar levels, which can prevent or delay complications of diabetes.
Choice C reason: This statement does not demonstrate health literacy by the client, but rather a need for more communication with their provider. Health literacy is not only about acquiring information, but also about using it effectively to make informed decisions. Asking to speak with their provider suggests that the client may have some questions or concerns that need to be addressed.
Choice D reason: This statement does not demonstrate health literacy by the client, but rather a need for more nutritional guidance. Health literacy is not only about understanding information, but also about acting on it to improve health outcomes. Requesting to speak with a nutritionist implies that the client may need some assistance with planning and following a healthy diet for diabetes.
Correct Answer is A
Explanation
Choice A reason: Critical thinking is a component of clinical decision-making that the nurse should use to make an evidence based decision. Critical thinking is the process of applying logic, reasoning, analysis, and evaluation to the information and evidence that is available. Critical thinking helps the nurse to identify and question assumptions, biases, and gaps in the data, and to draw valid and reliable conclusions based on the best available evidence.
Choice B reason: Clinical judgement is not a component of clinical decision-making, but an outcome of clinical decision-making. Clinical judgement is the result of applying critical thinking and clinical reasoning to the data and evidence that is gathered and interpreted. Clinical judgement is the expression of the nurse's decision or opinion about the client's situation, needs, and interventions.
Choice C reason: Concept mapping is not a component of clinical decision-making, but a tool or a strategy that can facilitate clinical decision-making. Concept mapping is a visual representation of the relationships among concepts, data, and evidence that are relevant to the client's situation. Concept mapping can help the nurse to organize, synthesize, and analyze the information, and to identify patterns, themes, and gaps in the data.
Choice D reason: Clinical reasoning is not a component of clinical decision-making, but a process that is involved in clinical decision-making. Clinical reasoning is the cognitive process that the nurse uses to collect, process, interpret, and integrate the data and evidence that is available. Clinical reasoning helps the nurse to make sense of the client's situation, needs, and responses, and to select the appropriate interventions and actions.
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