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 ["A","B","C","E"]

Explanation

A. Placing the bedside table within the client's reach helps to minimize the need for the older adult to reach or stretch, reducing the risk of falls.

B. Keeping the bed at a comfortable working height makes it easier for the older adult to get in and out of bed safely.

C. Keeping a night light on in the client's room and bathroom helps improve visibility during the night, reducing the risk of tripping or falling.

D. Administering a sedative at bedtime is generally not recommended as a preventive measure for falls. Sedatives can increase the risk of drowsiness and impaired balance, contributing to falls.

E. Locking the wheels on beds and wheelchairs during transfers helps ensure stability and prevents the equipment from moving unexpectedly, reducing the risk of falls during transfers.

A. Concurrent treatment for GERD B. History of breast cancer C. History of dermatitis D. Multiple hospitalizations for COPD

Correct Answer is B

Explanation

A. Concurrent treatment for GERD (gastroesophageal reflux disease) is not typically a contraindication for hormone replacement therapy. However, it's essential to assess the specific details of the client's medical history and medications to ensure safe use.

B. A history of breast cancer is a significant contraindication for hormone replacement therapy. Estrogen, a component of many HRT regimens, can stimulate the growth of certain types of breast cancer. Therefore, HRT is generally avoided in individuals with a history of breast cancer.

C. A history of dermatitis is not typically a contraindication for hormone replacement therapy. However, individual circumstances should be considered, and any concerns related to skin conditions should be discussed with the healthcare provider.

D. Multiple hospitalizations for COPD (chronic obstructive pulmonary disease) may not be a direct contraindication for hormone replacement therapy, but the overall health status and individual medical history should be carefully considered before initiating HRT.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is caring for a client who is experiencing menopausal symptoms and requests information about hormone replacement therapy (HRT). Which of the following items in the client's health history is a contraindication for hormone replacement therapy?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.)

A nurse is working with two assistive personnel (AP). The nurse notes that one of the APs has been taking long breaks and making personal phone calls. Which of the following statements should the nurse make to resolve this conflict?

A float nurse is given a client assignment that requires the use of unfamiliar skills and techniques. Which of the following actions should the nurse take?

A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)