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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. This response dismisses the client’s immediate needs and does not offer a supportive or constructive solution. It puts the responsibility on the client without addressing her request for assistance or exploring alternatives.
B. This is an appropriate and constructive response. It acknowledges the client’s situation and shows willingness to help find alternative resources, such as community services, meal delivery programs, or assistance from family or friends. This approach empowers the client and provides practical support.
C. While this response expresses willingness to help, it goes against the nurse's job description by implying that the nurse would perform tasks that are not permitted. It's important for the nurse to maintain professional boundaries and adhere to policies regarding their role.
D. This response is not appropriate because it focuses on the nurse's personal reasons and does not address the client's needs. It may come off as dismissive and fails to offer any alternative solutions or support.

A. "You have a low ferritin level." B. ‘You have an autoimmune disease." C. “You have fewer red blood cells." D. “You have had a gastrointestinal bleed."

Correct Answer is C

Explanation

A. While low ferritin levels can indicate iron deficiency anemia, sickle cell anemia primarily involves the production of abnormal hemoglobin rather than iron deficiency. Fatigue in sickle cell anemia is more closely related to the effects of the disease itself, including chronic hemolysis and decreased red blood cell survival.
B. Sickle cell anemia is not classified as an autoimmune disease; it is a genetic disorder caused by a mutation in the hemoglobin gene. While individuals with sickle cell anemia may have increased susceptibility to infections, the fatigue they experience is not due to an autoimmune process.
C. Sickle cell anemia leads to chronic hemolytic anemia, meaning the abnormal sickle-shaped red blood cells break down more quickly than normal red blood cells. This results in a lower overall red blood cell count (anemia), which can cause fatigue and weakness due to reduced oxygen-carrying capacity in the blood.
D. While gastrointestinal bleeding can lead to fatigue due to blood loss and subsequent anemia, it is not a direct consequence of sickle cell anemia. If the client had experienced a gastrointestinal bleed, it would typically need to be evaluated independently of their sickle cell disease.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has sickle cell anemia. The client asks. "Why do I feel so tired and fatigued all of the time?" Which of the following information should the nurse provide?

Correct Answer is C

Explanation

A nurse-manager discovered that a nurse was retrieving narcotics from sharps containers and has been abusing these medications for several months. When addressing this behavior and assisting the nurse, what factor should the manager prioritize?

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.)

Which infection control activity should the nurse delegate to an experienced unlicensed assistive personnel (UAP)?

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

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?

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?

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following health promotion strategies should the nurse include in the teaching?(Select All that Apply.)

Which of the following behaviors would not have disciplinary or legal consequences?