When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?

Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens.

Client fell out of bed, but did push the call button for assistance.

Recorder responded to client's call light, upon entering the room, found client on floor

Client became tangled in the bed linens, then called for assistance after falling out of bed.

Answer and Explanation

The Correct Answer is C

C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.

A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.

B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.

D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.

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Correct Answer is A

Explanation

A. By actively listening, the nurse shows empathy and a willingness to understand the client's perspective. Understanding significant events like a cancer diagnosis can help the nurse better anticipate the client's emotional and psychological needs.

B. This action shows support and encouragement for the client's achievements in managing their condition. It demonstrates the nurse's awareness of the client's efforts and competence in self-care. While it is positive reinforcement and supportive, it focuses more on the client's physical abilities rather than a deeper understanding of their personal experiences or emotions.

C. This action shows attentiveness to the client's physical comfort and emotional well-being. Offering a back rub during a bed bath can be soothing and comforting, addressing both physical and emotional needs. It demonstrates a caring approach to providing care that considers the client's comfort and relaxation.

D. Eye contact is an important non-verbal communication skill that conveys attentiveness and respect. It helps establish a connection and rapport between the nurse and the client. While maintaining eye contact is important for effective communication and building trust, it alone does not necessarily illustrate knowing the client in terms of understanding their personal experiences or emotions.

Correct Answer is ["1705"]

Explanation

To calculate the cumulative fluid intake for the client from 3 p.m. to 11 p.m., convert all measurements to the same unit and then sum them up.

First, convert ounces to milliliters (1 ounce = 29.5735 ml). The tea is 4 ounces, which is approximately 118 ml, and the soda is 6 ounces, approximately 177 ml.

Add all the liquid intake: chicken broth (120 ml) + tea (118 ml) + ice cream (assumed to be 240 ml for 1 cup) + soda (177 ml) + water (550 ml) + half the volume of ice chips (as half the volume of ice chips is water, so 250 ml). The total intake is 120 + 118 + 240 + 177 + 550 + 500= 1705 ml.

Since the intake and output are calculated at 2200, and the client has not consumed anything after 2115, the cumulative fluid intake for the shift is 1705 ml.

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When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which example best illustrates the principle of the nurse "knowing" the client? The nurse:

Correct Answer is A

Explanation

Correct Answer is ["1705"]

Explanation

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