A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
A client reports being dissatisfied with the temperature of the meals provided.
A client receives burns from a heating pad.
A client becomes disoriented and falls out of bed.
A client is unable to afford the physical therapy that the provider recommends.
A client's visitor's getting dizzy and fainting in the client's room
Correct Answer : B,C,E
Choice A reason: A client's dissatisfaction with the temperature of the meals is not an incident that requires a report. The nurse should inform the dietary staff and try to accommodate the client's preferences.
Choice B reason: A client's burns from a heating pad is an incident that requires a report. The nurse should document the cause, extent, and treatment of the burns, as well as the client's response and any actions taken to prevent recurrence.
Choice C reason: A client's disorientation and fall out of bed is an incident that requires a report. The nurse should document the circumstances, injuries, and interventions related to the fall, as well as the client's response and any changes in the plan of care.
Choice D reason: A client's inability to afford the physical therapy is not an incident that requires a report. The nurse should refer the client to a social worker or a financial counselor who can assist with finding resources and options.
Choice E reason: A client's visitor's dizziness and fainting in the client's room is an incident that requires a report. The nurse should document the event, the visitor's condition, and any actions taken to assist the visitor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because it reflects acceptance of the limb loss and a positive coping strategy. This statement shows that the client is willing to take responsibility for the care of the residual limb and is ready to learn new skills. The other statements indicate denial, anger, or depression, which are normal stages of grief, but not acceptance.
Choice B reason: This is not the correct answer because it reflects denial of the limb loss and a reluctance to face the reality of the situation.
Choice C reason: This is not the correct answer because it reflects depression and a sense of helplessness and dependency.
Choice D reason: This is not the correct answer because it reflects anger and a difficulty in adjusting to the limb loss.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because the crutch tips should be about 15 cm (6 inches) away from the feet to provide stability and prevent tripping.
Choice B reason: This is correct because the three-point gait involves bearing weight on the unaffected leg while moving both crutches and the affected leg forward at the same time.
Choice C reason: This is incorrect because the crutches should be at the level of the hips, not the waist, to avoid pressure on the axillae and nerves.
Choice D reason: This is incorrect because the arms should be slightly bent at the elbows when walking to reduce fatigue and strain.
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