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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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","E"]

Explanation

A. This is a routine task that can be safely delegated to a NAP. It does not require complex decision- making or assessment skills.
B. This task requires the ability to assess the client's condition and determine the appropriate level of restraint. It is a task that should be performed by an RN or licensed practical nurse (LPN).
C. While this may seem like a simple task, it requires the ability to monitor the client for signs of withdrawal and to intervene if necessary. It is a task that should be performed by an RN or LPN.
D. This task requires the ability to assess the client's behavior and to intervene if necessary. It is a task that should be performed by an RN or LPN.
E. This is a therapeutic activity that can be delegated to a NAP. It can help to stimulate the client's cognitive function and provide social interaction.
F. This task requires the ability to assess the client's condition and identify potential complications. It is a task that should be performed by an RN or LPN.

A. “Do you think it would be a good idea to have an in-service on dealing with Alzheimer's patients?” B. “You must remember to watch your tone of voice with clients. Someone might overhear." C. “I have decided to reassign that client to another aide." D. “I am concerned about your conversation with the client. It sounded short and impatient”

Correct Answer is D

Explanation

A. While suggesting an in-service could be beneficial in the long run, it is not an immediate or direct approach to addressing the specific behavior observed. This statement deflects from the issue at hand and may not convey the urgency needed in correcting the aide's behavior.
B. This statement is somewhat vague and could come across as patronizing or defensive. While it points out the need to be mindful of tone, it does not specifically address the emotional impact of the aide’s behavior on the client or acknowledge the situation effectively. It focuses on appearance rather than the well-being of the patient.
C. This approach does not address the underlying issue of the aide's behavior and may create a confrontational or punitive atmosphere. It can also foster resentment rather than promote learning and improvement. It's essential to address behaviors directly instead of merely reassigning responsibilities.
D. This statement is direct and addresses the specific behavior observed. It expresses concern without being accusatory and opens a dialogue about the aide’s communication style. This approach encourages reflection and offers the aide an opportunity to discuss and understand how their tone may affect clients, especially those with cognitive impairments like Alzheimer's.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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]

Correct Answer is ["A","E"]

Explanation

The RN overbears the nurses' aide speaking in a harsh tone to a client with early Alzheimer's memory loss. Which statement should the EN make to begin addressing this issue?

Correct Answer is D

Explanation

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment?

When monitoring medication inventories for possible diversion or theft by nurses who abuse chemicals, what medication classifications should be monitored most closely? [SELECT ALL THAT APPLY]

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?

A client with frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN?

Which term best describes sickle cell disease?

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 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.)