The nurse responds to a voice calling out from a room on the nursing unit. Upon entering the room, the nurse sees a patient lying on the floor near the foot of the bed. After attending to the patient and notifying the HCP, which notation would be most appropriate to record on the incident occurrence report?

Patient found lying on floor at foot of the bed.

Patient was rushing to the bathroom to avoid incontinence.

Patient fell while walking to the bathroom.

Patient states nursing staff did not respond to the call bell.

Answer and Explanation

The Correct Answer is A

A.   This statement is the most appropriate for an incident occurrence report. It provides a factual, objective description of what was observed without inferring causes or making assumptions about the patient’s actions. Clear documentation is critical in incident reports for accuracy and potential follow-up.
B.   This statement includes assumptions about the patient's motivations and actions. It is speculative and not based on direct observation. Incident reports should avoid subjective interpretations and focus on what can be objectively verified.
C.   Although this statement describes a potential scenario, it assumes that the patient was walking to the bathroom and that this was the cause of the fall. Since the nurse did not witness the event, this could be misleading and should be avoided in an incident report.
D.   While documenting patient statements can be important, this particular comment is subjective and does not provide an objective account of the incident. It could also lead to potential blame without verifying the accuracy of the statement, which could complicate the report.

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Correct Answer is C

Explanation

A. While track marks could indicate drug use, this alone does not necessitate a report to an outside agency unless there is evidence of harm to self or others, or if there are suspicions of a substance abuse issue that warrants intervention.

B. Emancipated minors have the legal right to make their own medical decisions, including refusing treatment. In this case, the nurse would ensure the patient is informed of the risks of leaving and document the refusal, but there’s no requirement to disclose to an outside agency.
C. A spiral fracture can be indicative of abuse, particularly if the mechanism of injury is not consistent with the explanation provided. In many jurisdictions, healthcare providers are mandated reporters for suspected abuse or neglect in dependent adults.
D. This situation typically does not involve any legal or ethical obligation to report to outside agencies. Glomerulonephritis is a medical condition and does not indicate any need for disclosure, as it does not suggest abuse or neglect.

A. Patient found lying on floor at foot of the bed. B. Patient was rushing to the bathroom to avoid incontinence. C. Patient fell while walking to the bathroom. D. Patient states nursing staff did not respond to the call bell.

Correct Answer is A

Explanation

A. This statement is the most appropriate for an incident occurrence report. It provides a factual, objective description of what was observed without inferring causes or making assumptions about the patient’s actions. Clear documentation is critical in incident reports for accuracy and potential follow-up.
B. This statement includes assumptions about the patient's motivations and actions. It is speculative and not based on direct observation. Incident reports should avoid subjective interpretations and focus on what can be objectively verified.
C. Although this statement describes a potential scenario, it assumes that the patient was walking to the bathroom and that this was the cause of the fall. Since the nurse did not witness the event, this could be misleading and should be avoided in an incident report.
D. While documenting patient statements can be important, this particular comment is subjective and does not provide an objective account of the incident. It could also lead to potential blame without verifying the accuracy of the statement, which could complicate the report.

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Naxlex Comprehensive Predictor Exams

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY]

A member of the team has been delegated some tasks and reports, "I've been given too much to do and I'm not going to be able to complete the work on time." What is the RN's best initial action?

A nurse at a community clinic is reinforcing education for a newly licensed nurse about nursing advocacy. Which of the following actions should the nurse include as an example of nursing advocacy?

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia?(Select All that Apply.)

In which situation would the nurse be justified in overriding a client's right to confidentiality?

A nurse is admitting a client who has sickle cell anemia. Which of the following manifestations should the nurse expect with this condition?(Select All that Apply.)

A nurse is uncharacteristically extroverted on today's shift, with an unsteady gait. The manager suspects that the nurse may be chemically Impaired. What is the manager's most appropriate action?

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?