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?
Complete an incident report.
Notify the client's provider.
Document the fall in the client's medical record.
Measure the client's vital signs.
The Correct Answer is D
The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Memory loss that disrupts activities of daily living (ADLs) is a common manifestation of dementia, which is a progressive decline in cognitive function. Pressured speech, catatonia, and illusions are more likely to be seen in clients who have psychotic disorders, such as schizophrenia or bipolar disorder.
Correct Answer is A
Explanation
Explanation: The first step in bladder training is to assess the client's baseline bladder function and identify factors that may affect it, such as fluid intake, medications, or mobility issues. The other interventions are part of bladder training but should be implemented after assessment.
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