A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

Sends the incident report to the ethics committee

Lists names of witnesses to the fall in the nurses' notes

Includes the client's account of the fall in the incident report

Documents in the client's record that an incident report was filed

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.

Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.

Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.

Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.

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Correct Answer is D

Explanation

Choice A reason: Taking pictures of the child's injuries once the parent leaves the room is not a correct action, as it violates the child's privacy and dignity. The nurse should not take pictures of the child without the parent's consent and only if it is required by the facility's policy or the law.

Choice B reason: Having a facility security officer interview the parent is not a correct action, as it is not within the scope of the security officer's role and may escalate the situation. The nurse should not involve the security officer unless there is a threat of violence or harm to the child, the parent, or the staff.

Choice C reason: Completing an incident report concerning the child's injuries is not a correct action, as it is not relevant to the child's situation. The nurse should complete an incident report only if there is an adverse event or error that occurred within the facility that affected the child's care or safety.

Choice D reason: Reporting the child's injuries to Child Protective Services is the correct action, as it is the nurse's legal and ethical duty to protect the child from potential abuse or neglect. The nurse should suspect child abuse based on the child's injuries, which are inconsistent with the parent's explanation and indicative of non-accidental trauma. The nurse should follow the facility's protocol and the state's law for reporting suspected child abuse.

A. "I cannot provide this information to you without your mother's consent." B. "What would you like to know about your mother's treatment?" C. "You will have to speak directly to your mother about her treatment." D. "I will ask your mother's primary care provider to speak with you."

Correct Answer is A

Explanation

Choice A reason: This is the correct response by the nurse. The nurse should respect the client's right to privacy and confidentiality and not disclose any information about the client's treatment plan without the client's consent. The nurse should also inform the adult child that they can ask their mother for permission to access her medical records.

Choice B reason: This is not the correct response by the nurse. The nurse should not ask the adult child what they want to know about the client's treatment, as this implies that the nurse is willing to share the information without the client's consent. The nurse should only answer the questions that the client has authorized the nurse to answer.

Choice C reason: This is not the correct response by the nurse. The nurse should not tell the adult child to speak directly to their mother about her treatment, as this may put pressure on the client to reveal information that she may not want to share. The nurse should respect the client's autonomy and decision-making regarding her treatment plan.

Choice D reason: This is not the correct response by the nurse. The nurse should not ask the client's primary care provider to speak with the adult child, as this may violate the client's privacy and confidentiality. The nurse should only involve the primary care provider if the client has given consent or if there is a legal or ethical obligation to do so.

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A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?

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