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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Ulcerative colitis can lead to iron deficiency anemia due to chronic inflammation, intestinal bleeding, and malabsorption of nutrients. The disease often affects the colon, which can result in blood loss and inadequate iron absorption.
B. A diet high in prepackaged and processed foods is often low in essential nutrients, including iron. These foods may lack whole grains, fruits, vegetables, and other sources of dietary iron, increasing the risk of iron deficiency anemia.
C. Treatment for gastrointestinal cancer, such as surgery or chemotherapy, can lead to changes in absorption and increased risk of bleeding. This history can significantly elevate the risk for developing iron deficiency anemia due to potential blood loss and malabsorption issues.
D. Gastric bypass surgery can lead to iron deficiency anemia due to reduced stomach size and changes in the gastrointestinal tract that impair nutrient absorption. Patients often need to supplement their diet with iron and other vitamins after surgery.
E. Eating red meat daily is generally associated with an adequate intake of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant sources. While it's important to consider overall dietary patterns, this particular factor does not typically pose a risk for iron deficiency anemia.

A. Frequent handwashing B. Avoiding the annual flu vaccine. C. Taking an iron supplement daily D. Visiting the eye doctor annually E. Joining a support group

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

Explanation

A. Frequent handwashing is an important health promotion strategy for individuals with sickle cell disease. They are at increased risk for infections due to potential splenic dysfunction. Good hand hygiene helps reduce the risk of infections, which can trigger a sickle cell crisis.
B. Clients with sickle cell disease are strongly encouraged to receive the annual flu vaccine. Influenza can lead to serious complications in these patients, including increased risk of respiratory infections and sickle cell crises. Vaccination is a key preventive measure.
C. Routine iron supplementation is not typically recommended for individuals with sickle cell disease unless there is a specific diagnosis of iron deficiency anemia. Sickle cell patients can have normal or elevated ferritin levels, and unnecessary iron supplementation can lead to iron overload, which is harmful.
D. Regular eye examinations are important for individuals with sickle cell disease, as they are at risk for ocular complications, including retinopathy. Annual visits help monitor eye health and prevent vision problems.
E. Joining a support group can be beneficial for individuals with sickle cell disease. It provides emotional support, education, and a sense of community. Sharing experiences with others who understand the challenges of living with the disease can enhance coping strategies and overall well-being.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["A","B","C","D"]

Explanation

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.)

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

Explanation

A nurse is preparing to administer morphine IV to a client. Which of the following medications should the nurse plan to have available?

A registered nurse has been leading teams of nursing assistive personnel (NAP) for several years and will soon be leading licensed practical nurses (LPNs) for the first time. In preparation for delegating to these nurses, the RN should:

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?

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 teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?

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?