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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Standing on the client's stronger side may cause the client to lean or fall toward the weaker side. The nurse should stand on the client's weaker side and support the client's trunk and affected arm.

Choice B reason: Raising the bed to waist level may make it harder for the client to move their legs over the edge of the bed. The nurse should lower the bed to the lowest position and raise the head of the bed to a sitting position.

Choice C reason: Flexing hips and knees helps the client use their stronger leg muscles and maintain balance when standing up. The nurse should also place one arm under the client's axilla and the other arm around the client's waist.

Choice D reason: Pivoting on the foot farthest from the bed may cause the client to lose balance and fall. The nurse should pivot on the foot closest to the bed and guide the client to turn and sit on the chair.

A. He may need a feeding tube. B. Why do you think he's not eating? C. I'm sure it's nothing serious and his appetite will return soon. D. Tell me more about what happens at mealtime.

Correct Answer is D

Explanation

Choice A reason: This is incorrect because suggesting a feeding tube is premature and may alarm the son without knowing the cause of the client's poor appetite.

Choice B reason: This is incorrect because asking why the son thinks the client is not eating may imply that the son is responsible or has the answer, which may make him feel defensive or guilty.

Choice C reason: This is incorrect because dismissing the son's concern as nothing serious may make him feel unheard or invalidated, and may also delay seeking appropriate help for the client.

Choice D reason: This is correct because asking the son to tell more about what happens at mealtime is an open-ended question that shows interest and empathy, and may elicit more information about the client's condition and preferences.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

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Explanation

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Correct Answer is D

Explanation

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