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 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.

A. The program is unnecessary because state boards of nursing have authority over this issue. B. The program should emphasize punishment due to the safety risk posed by impaired employees. C. For confidentiality reasons, the program should be planned and executed by the personnel department. D. The program should emphasize screening, prevention and early intervention.

Correct Answer is D

Explanation

A. While state boards of nursing do have regulatory authority over nursing practice and can take action against nurses who abuse substances, this does not negate the need for an internal program. Organizations should proactively address substance abuse to support employee health and safety, rather than relying solely on external authorities.
B. While safety is a critical concern, emphasizing punishment can create a culture of fear and may discourage employees from seeking help. A punitive approach may lead to further issues, such as hiding problems rather than addressing them.
C. While confidentiality is important, the involvement of the personnel department alone may not be sufficient to address the complexities of substance abuse. A comprehensive program should include input from healthcare professionals, mental health experts, and employee assistance programs to effectively manage and support affected employees.
D. This is the most appropriate consideration. A program focusing on screening, prevention, and early intervention can help identify issues before they escalate, support employees in getting the help they need, and create a healthier workplace culture.

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Naxlex Comprehensive Predictor Exams

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

What consideration should the nurse-manager prioritize when creating a program to deal with the issue of substance abuse by employees?

Correct Answer is D

Explanation

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]

The care of a client is assigned to a newly-graduated RN. What actions can the newly-graduated RN delegate to the unlicensed assistive personnel (UAP)? [SELECT ALL THAT APPLY]

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?

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 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.)