You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the floor.
What is your first step in the nursing process in this situation?
Leave the patient to get help.
Call the patient’s health-care provider from your cell phone.
Help the patient get up and then document your findings in the chart.
Gather more information by making observations about the patient.
The Correct Answer is D
The first step in the nursing process is assessment, which involves gathering information about the patient’s condition. In this situation, the nurse should make observations about the patient’s physical and mental status, including any signs of injury or distress. This information can then be used to determine the appropriate course of action and provide appropriate care. The other
The other options do not represent the first step in the nursing process and may not be appropriate in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Breach of confidentiality occurs when private and sensitive information is disclosed to others without the client's consent. In this scenario, the co-workers are discussing a client's mental health condition in a public place where their conversation can be overheard by others. This is a violation of the client's right to privacy and confidentiality.
The co-workers could be held liable for breaching the client's confidentiality and may face disciplinary action or legal consequences. It is important for healthcare providers to maintain confidentiality to protect their clients' privacy and trust.
Correct Answer is D
Explanation
This client’s behavior indicates that they may pose a danger to themselves or others and may require immediate intervention to ensure their safety and the safety of those around them.
The other clients (a, b, c) may also have mental health needs, but their situations do not necessarily indicate the need for emergency admission to a mental hospital. It is important for healthcare providers to assess each client’s individual needs and to provide appropriate care and support.
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