A nurse is assisting with the care of a client who is admitted to the medical surgical unit.

Complete the following sentences by using the list of options:

The nurse anticipates the client will likely require

______

as evidenced by the client’s

_______

and

______

.

A) "The client fell because the assistive personnel did not place nonskid slippers on the client.": This statement assigns blame to a specific individual (assistive personnel) for the fall, which is not appropriate for documentation. The nurse should focus on factual, objective information rather than assigning blame. Statements that imply fault without proper evidence or investigation should be avoided in medical records.

B) *Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom.'": This statement accurately reflects the client’s account of the incident, which is a critical part of the documentation. The nurse should include the client’s own words when describing the event, as it provides essential context and ensures that the record is clear and unbiased. This statement is objective and factual.

C) "The client does not appear to have any injuries resulting from the fall.": While it’s important to assess for injuries, this statement could be too vague. The nurse should document a detailed assessment of the client’s physical condition post-fall, including any injuries, signs, or symptoms of injury. It is important to be thorough and specific in documenting the client's condition after the fall.

D) "An incident report has been completed and sent to risk management.": This information should not be included in the medical record. Incident reports are separate documents that are used for internal review and safety improvement purposes. Including this information in the medical record could lead to confusion and may not be relevant to the clinical care of the client.

A) I have occasional vaginal spotting: Vaginal spotting can occur as a side effect of medroxyprogesterone, especially in the first few months of use. While this should be monitored, it is not an immediate concern that requires urgent reporting unless the spotting becomes heavy or persistent, which could indicate other issues.

B) I have developed brown patches on my face: The development of brown patches on the face (known as melasma) is a known side effect of hormonal contraceptives, including medroxyprogesterone. Although this is an undesirable cosmetic effect, it is not an urgent medical concern that requires immediate attention.

C) I have breast tenderness: Breast tenderness is a common side effect of medroxyprogesterone and other hormonal medications. It is usually mild and resolves over time. While the client should continue to monitor the tenderness, it does not present an immediate risk or require urgent intervention.

D) I have intermittent calf pain: Intermittent calf pain could be a sign of a more serious complication, such as a deep vein thrombosis (DVT), especially since medroxyprogesterone can increase the risk of blood clots. This symptom should be reported immediately to the healthcare provider, as a DVT could potentially lead to a pulmonary embolism if left untreated, which is a life-threatening condition. Therefore, this is the priority finding to report.