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 D
Explanation
Choice A reason: Preventing opioid use is not a benefit of de-escalation techniques. Opioid use is a complex issue that involves biological, psychological, and social factors, and cannot be prevented by simply deescalating emotional situations. De-escalation techniques may help to calm or soothe someone who is experiencing pain or distress, but they do not address the underlying causes or consequences of opioid use.
Choice B reason: Increasing communication is not a benefit of de-escalation techniques, but a means or a strategy to achieve de-escalation. Communication is an essential skill that helps to deescalate emotional situations by listening, validating, empathizing, and problem solving with the other person. Communication can also help to prevent or reduce conflicts, misunderstandings, and aggression. However, communication is not an outcome or a result of de-escalation, but a process or a tool to facilitate de-escalation.
Choice C reason: Decreasing hallucinations is not a benefit of de-escalation techniques. Hallucinations are perceptual disturbances that involve seeing, hearing, feeling, smelling, or tasting things that are not there. Hallucinations can be caused by various factors, such as mental disorders, neurological conditions, substance use, or medication side effects. De-escalation techniques may help to manage or cope with hallucinations, but they do not treat or eliminate them.
Choice D reason: Reducing restraint use is a benefit of de-escalation techniques. Restraint use is a practice that involves restricting the movement or behavior of a person who poses a risk of harm to themselves or others. Restraint use can have negative effects on the physical and psychological wellbeing of the person, such as injuries, infections, agitation, and trauma. De-escalation techniques can help to avoid or minimize the need for restraint use by resolving or calming emotional situations in a safe and respectful manner.
Correct Answer is A
Explanation
Choice A: This is the correct answer. A portal is a secure online platform that enables clients to access their health information, communicate with their providers, request appointments, refill prescriptions, and more. This enhances client satisfaction, engagement, and empowerment.
Choice B: This is incorrect. Same day access to client health record is not an advantage of electronic documentation, but a requirement for any documentation system. Clients have the right to access their health information within a reasonable time frame, regardless of whether it is paper-based or electronic.
Choice C: This is incorrect. The increase of duplicate tests performed on client is not an advantage of electronic documentation, but a disadvantage. Duplicate tests can result from poor communication, lack of interoperability, or human error. Electronic documentation can help reduce duplicate tests by facilitating data sharing, standardizing formats, and alerting providers of previous tests.
Choice D: This is incorrect. Decrease in coordination of client care is not an advantage of electronic documentation, but a disadvantage. Coordination of client care is essential for ensuring quality, safety, and continuity of care. Electronic documentation can improve coordination of client care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools.
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