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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Provide support by holding the client's arm:

While providing support is essential, holding the client's arm may not prevent a fall. It's better to focus on a controlled descent to the floor.

B. Maintain a narrow base of support:

Maintaining a narrow base of support is not advisable when a client is falling. A wider base of support provides more stability.

C. Lower the client to the floor:

This is the correct action. When a client begins to fall, the nurse should lower them to the floor in a controlled manner to minimize the risk of injury.

D. Lean the client toward the wall:

Leaning the client toward the wall may not provide sufficient support during a fall. The goal is to lower the client to the floor in a way that minimizes the risk of injury.

A. A 15-year old client who has acne B. A client who has a menstrual cycle every 14 days C. A client who has a blood pressure of 140/90 mm Hg D. A client who has a hematocrit of 39%

Correct Answer is C

Explanation

A. A 15-year-old client who has acne:

Acne alone is not a contraindication to oral contraceptives. In fact, oral contraceptives can sometimes be prescribed to help manage acne.

B. A client who has a menstrual cycle every 14 days:

Having a menstrual cycle every 14 days may indicate an irregular cycle, but it's not a direct contraindication to oral contraceptives. However, the cause of the frequent cycles might need evaluation before starting oral contraceptives.

C. A client who has a blood pressure of 140/90 mm Hg:

Elevated blood pressure (140/90 mm Hg or higher) is a contraindication to oral contraceptives. It increases the risk of complications such as stroke, heart attack, or other cardiovascular issues.

D. A client who has a hematocrit of 39%:

A hematocrit level of 39% is within the normal range and is not a contraindication to oral contraceptives.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients as having a contraindication to oral contraceptives?

Correct Answer is C

Explanation

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