A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
Notify the client's provider.
Measure the client's vital signs.
Complete an incident report.
Document the fall in the client's medical record.
The Correct Answer is B
When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. This assessment helps determine if there are any immediate medical concerns resulting from the fall, such as injury or shock, that require prompt attention.
The other options listed are also important but should be addressed after the initial assessment and safety measures:
A. Notify the client's provider: After assessing the client's condition, if there are significant injuries or concerns identified, the nurse should promptly notify the client's provider to seek further medical guidance and intervention.
C. Complete an incident report: Reporting the fall incident is an essential part of ensuring quality and safety in healthcare. However, it is not the first action the nurse should take. The immediate focus should be on the client's assessment and safety. Completing an incident report can be done once the client's immediate needs are addressed.
D. Document the fall in the client's medical record: Documenting the fall in the client's medical record is important for maintaining accurate and comprehensive documentation. However, it should be done after the client's assessment, vital sign measurement, and any necessary interventions have been carried out.
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Related Questions
Correct Answer is C
Explanation
Helping the client develop positive self-talk and challenging negative thoughts can be beneficial in managing depressive symptoms. Assisting the client in recognizing negative self-perceptions and replacing them with more positive and realistic thoughts can help improve mood and self-esteem.
Exercise has been shown to have mood-enhancing effects and can help alleviate symptoms of depression. However, exercise should be done earlier in the day rather than right before bedtime, as it can have stimulating effects that may interfere with sleep.
It is important to encourage the client to engage in activities and spend time with others. Isolation and spending excessive time alone can exacerbate depressive symptoms. However, it is also important to respect the client's need for privacy and personal space.
While diet does play a role in overall well-being, there is no specific evidence to support the use of low-protein snacks for the treatment of major depressive disorder. It is important to provide the client with a well-balanced diet that includes a variety of nutrients to support overall health.
Correct Answer is D
Explanation
After a laparoscopic cholecystectomy, steri-strips or adhesive strips are commonly placed over the small incisions. The client should keep the steri-strips in place until they fall off on their own or until they are removed by the healthcare provider during a follow-up visit. Removing the steri-strips prematurely can increase the risk of infection or disrupt the healing process.
"I should eat a high-fat diet for several weeks": After a laparoscopic cholecystectomy, it is important for the client to follow a low-fat diet initially to allow the body time to adjust to the absence of the gallbladder. High-fat foods can be more difficult to digest and may cause digestive discomfort. Gradually introducing small amounts of fat back into the diet is recommended, but a high-fat diet is not appropriate.
"I should expect to have diarrhea until my diet changes": While changes in bowel movements can occur after a cholecystectomy, such as looser stools or changes in frequency, persistent diarrhea is not expected or normal. If the client experiences persistent diarrhea, they should contact their healthcare provider for further evaluation.
"I should expect to have nausea for several days": While some clients may experience mild nausea or discomfort after the surgery, it should generally improve within a few days. If the client experiences persistent or severe nausea, they should contact their healthcare provider.
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