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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Related Questions
Correct Answer is D
Explanation
Choice A reason: If client is uninsured the ED can decline to render services is not an information that the nurse should include in the teaching. This is a false statement that contradicts the purpose and the provision of EMTALA. According to EMTALA, any hospital that participates in Medicare and has an emergency department must provide an appropriate medical screening examination to anyone who requests it, regardless of their insurance status or ability to pay.
Choice B reason: The ED has the right to refuse to provide client services is not an information that the nurse should include in the teaching. This is a false statement that violates the principle and the requirement of EMTALA. According to EMTALA, any hospital that participates in Medicare and has an emergency department has a duty to provide stabilizing treatment to any individual who has an emergency medical condition or is in active labor, unless an appropriate transfer is arranged.
Choice C reason: The ED can transfer medically unstable clients to other facilities is not an information that the nurse should include in the teaching. This is a false statement that breaches the rule and the regulation of EMTALA. According to EMTALA, any hospital that participates in Medicare and has an emergency department must not transfer an individual who has an emergency medical condition or is in active labor, unless the transfer is requested by the individual or their representative, or the transfer meets certain criteria, such as the benefits outweigh the risks, the receiving facility has agreed to accept the transfer, and the transfer is effected by qualified personnel and equipment.
Choice D reason: Clients must receive a medical screening evaluation (MSE) is an information that the nurse should include in the teaching. This is a true statement that reflects the essence and the standard of EMTALA. According to EMTALA, any hospital that participates in Medicare and has an emergency department must provide an appropriate medical screening examination to anyone who comes to the emergency department and requests examination or treatment for a medical condition, to determine whether or not an emergency medical condition exists
Correct Answer is C
Explanation
Choice A reason: The prodromal stage is the period between the exposure to the infectious agent and the onset of specific symptoms. During this stage, the person may experience mild and nonspecific signs of infection, such as fatigue or lowgrade fever. The client in the question has already developed specific symptoms of infection, such as sneezing, productive cough, and fever, which indicate that they have passed the prodromal stage.
Choice B reason: The period of convalescence is the stage of recovery after the infection. During this stage, the person's symptoms gradually subside, and their immune system eliminates the infectious agent from the body. The client in the question is still experiencing symptoms of infection, which suggest that they have not reached the period of convalescence yet.
Choice C reason: The acute illness stage is the peak of the infection, when the person exhibits the most severe and specific symptoms of the disease. During this stage, the person's immune system fights against the infectious agent, and the outcome of the infection is determined. The client in the question is likely in the acute illness stage, as they have been experiencing symptoms of infection for 4 days, and their condition has worsened over time.
Choice D reason: The incubation stage is the time between the entry of the infectious agent into the body and the appearance of the first symptoms of infection. During this stage, the person does not feel ill, but the infectious agent is multiplying in the body. The client in the question has already developed symptoms of infection, which indicate that they have left the incubation stage.
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