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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Delirium is often reversible once the underlying cause is identified and treated (e.g., correcting electrolyte imbalances, managing infections, discontinuing medications contributing to delirium). With appropriate intervention, the mental status can improve, and the individual can return to their baseline cognitive function.
A. Dementia, on the other hand, is a chronic, progressive syndrome that primarily affects memory, thinking, behavior, and the ability to perform everyday activities. It does not typically cause acute changes in consciousness.
B. Memory impairment is a hallmark feature of dementia, especially in the early stages. In contrast, delirium primarily affects attention, awareness, and cognition acutely, with memory impairment being variable and not a defining feature.
D. Delirium develops rapidly, often over hours to days, in response to an acute medical condition, medication change, or other factors. It is characterized by a fluctuating course and can resolve once the underlying cause is managed.
Correct Answer is ["A","B","C","E"]
Explanation
A. Clients with dementia often experience cognitive decline, which can affect their ability to navigate their surroundings safely. Modifying the environment can include simplifying the layout, reducing clutter, using clear signage, and ensuring adequate lighting to enhance orientation and reduce confusion.
B. Communication difficulties are common in dementia. Using short, simple sentences helps clients better understand instructions and information. It reduces confusion and frustration, promoting effective communication and cooperation during care.
C. Maintaining independence and dignity is crucial for clients with dementia. Allowing them to participate in Activities of Daily Living (ADLs) to the extent possible helps preserve their functional abilities, boosts their self-esteem, and promotes a sense of control over their environment.
E. Providing choices within a structured framework can empower clients with dementia. It allows them to maintain some control over their daily routine and decisions, thereby enhancing their sense of autonomy and reducing agitation or resistance to care.
D. This is not an appropriate intervention. Social interaction, including visits from family members, can have significant emotional and psychological benefits for clients with dementia. It can help reduce feelings of isolation, improve mood, and provide reassurance and familiarity.
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