A nurse discovers a patient lying on the floor. Which should the nurse write when completing an incident report?
Patient accidentally fell out of bed onto the floor.
Heard patient fall from the bed to the floor.
Found patient lying face down on the floor beside the bed.
Patient fell out of bed onto the floor.
The Correct Answer is C
Choice A rationale
An incident report must be a factual, objective, and non-judgmental account of what the nurse directly observed. Stating that the "Patient accidentally fell out of bed" includes an assumption of the cause ("accidentally fell") which is a conclusion. The nurse did not witness the act of falling, so they must only report the facts of their discovery to ensure legal accuracy.
Choice B rationale
Reporting "Heard patient fall from the bed" includes an inference about the source of the sound ("fall from the bed") and is not strictly a documented fact. While the nurse may have heard a noise, the most objective reporting focuses on the verifiable observation upon entering the room, which is the patient's physical location and position at the time of discovery.
Choice C rationale
Stating, "Found patient lying face down on the floor beside the bed" is the most objective and factual description. This phrasing avoids making assumptions about the cause of the event (e.g., "fell") and clearly documents the precise observation made by the nurse upon entering the room, which is essential for an incident report and subsequent investigation.
Choice D rationale
Similar to Choice A, the statement "Patient fell out of bed onto the floor" is a conclusion or inference because the nurse did not witness the event. The fundamental principle of incident reporting is to document what was seen, heard, or done, without speculation, to ensure the report is a truthful and unbiased account of the facts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The Medication Administration Record (MAR) is a legal document used to track the scheduling and administration of all medications. While vital for drug-related information, the MAR is not a comprehensive tool for providing a holistic report on the client's overall status, care plan, or recent changes needed for an ongoing shift report.
Choice B rationale
The Kardex is a client care summary that provides concise, quick reference information about the client's diagnosis, orders, treatments, scheduled tests, and care needs. Although increasingly digitized, this system (or its electronic equivalent) is specifically designed to facilitate organized, efficient shift-to-shift reporting by summarizing key data points.
Choice C rationale
A Narrative chart note is a descriptive written account of an event, assessment, or intervention and is a component of the legal medical record. While it contains valuable data, using an entire narrative note for shift report is inefficient, as the Kardex or a standardized handoff system (like SBAR) is preferred for a structured and time-efficient handoff.
Choice D rationale
Personal notes written during a shift assessment are considered memory aids and are not part of the legal client record. Providing a report based solely on non-validated, personal notes is unacceptable because it is unprofessional, lacks standardization, and risks incomplete or inaccurate information transfer, violating professional standards.
Correct Answer is D
Explanation
Choice A rationale
While the information used in a concept map may relate to the patient's existing care plan, the primary focus of creating a concept map as a learning tool is synthesis and organization of information, not merely validation of a pre-existing plan. The map helps the student link theoretical knowledge to the patient's specific clinical presentation.
Choice B rationale
Although assessment data collection is the foundational step providing the map's content, focusing solely on it misses the map's critical function: visually organizing the data, identifying relationships between problems, clustering related concepts, and ultimately planning care according to a logical framework, which extends beyond data gathering.
Choice C rationale
Evaluating outcomes is a distinct, later phase of the nursing process (Nurses Are Planning to Implement Evaluating- Nursing Assessment Planning Implementation Evaluation). While the student might review past outcomes, the preparation phase using a concept map is designed to organize information and develop the subsequent steps of the care plan, not primarily to evaluate past actions.
Choice D rationale
The most effective use of a concept map in nursing education is its adherence to the nursing process structure. The map visually represents the patient's condition (Assessment), identifies key issues (Diagnosis), links them to goals (Planning), and outlines necessary actions (Interventions), thereby teaching the student a systematic and holistic approach to patient care.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.