A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record?
"Client fell out of bed and cut his forehead due to sedative-induced confusion."
"Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."
"Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."
"Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in medical record for further details."
The Correct Answer is C
A. "Client fell out of bed and cut his forehead due to sedative-induced confusion."
This option provides information about the fall and the cause but lacks specific details about the injury, location, or the client's orientation. It is not as detailed or objective as it could be.
B. "Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime."
This option includes information about the client's position, the presence of blood, and attributes the fall to the failure of the assistive personnel to put up side rails. While it provides some details, it introduces an element of blame and speculation. It's important to stick to factual information in documentation.
C. "Client found lying on the floor with a 3-cm laceration 1 cm above left eyebrow. Client oriented to name only."
This option provides specific details about the client's position, the nature and location of the injury (laceration), and the client's orientation status. It is concise, objective, and focused on the relevant information.
D. "Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in the medical record for further details."
This option includes information about the fall, the injury, and refers to an incident report for further details. While it provides information, it may be more appropriate to include essential details directly in the documentation rather than referring to another document for additional information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. A client who has had prolonged diarrhea:
Prolonged diarrhea is not typically associated with an increased risk of aspiration during eating.
B. A client who has lactose intolerance:
Lactose intolerance primarily affects the ability to digest lactose-containing foods and does not directly increase the risk of aspiration.
C. A client who has had radiation therapy for head and neck cancer:
Radiation therapy to the head and neck can cause damage to the structures involved in swallowing, increasing the risk of aspiration.
D. A client who has had a stroke:
Stroke can affect the coordination of swallowing muscles, leading to dysphagia (difficulty swallowing) and an increased risk of aspiration.
E. A client who is 4 hr postoperative following a leg amputation under general anesthesia:
Postoperative clients under general anesthesia may experience impaired protective airway reflexes, making them prone to aspiration. It's important to monitor these clients closely during the initial recovery period.
Correct Answer is B
Explanation
A. "The doctor can best help you with that after your physical examination."
This response implies that a physical examination is necessary before discussing contraception, which may not be accurate. Contraceptive counseling can often occur without a physical examination, and the nurse can provide initial guidance based on the information available.
B. "Before I can help you with that question, I need to know more about your sexual activity."
This response is appropriate because it acknowledges the need for more information to provide personalized advice. It respects the individual's privacy while recognizing that different contraceptive methods may be suitable based on factors like sexual activity, health history, and personal preferences.
C. "You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?"
This response may come across as judgmental and could potentially discourage open communication. It's essential to maintain a non-judgmental and supportive attitude when discussing sexual health with adolescents. Instead of questioning their readiness, the focus should be on providing accurate information and support.
D. "Because of your age, we need your parents' consent for an examination, and then we'll talk."
This response may not be appropriate as it suggests a potential barrier to seeking advice about contraception. Many jurisdictions allow adolescents to receive confidential reproductive health services, including contraception, without parental consent. Encouraging open communication and respecting confidentiality is crucial in supporting adolescents' access to reproductive healthcare.
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