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 receives burns from a heating pad.

A client reports being dissatisfied with the temperature of the meals provided.

A client becomes disoriented and falls out of bed.

A client's visitor becomes dizzy and faints in the client's room.

A client is unable to afford the physical therapy that the provider recommends.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale

A client who receives burns from a heating pad has experienced harm due to the healthcare setting or treatment. An incident report should be completed to document the injury and investigate the cause to prevent future occurrences.

Choice B rationale

A client's dissatisfaction with meal temperature does not typically require an incident report unless it leads to significant issues such as foodborne illness or other adverse effects. It is usually managed through the facility's complaint process.

Choice C rationale

If a client becomes disoriented and falls out of bed, it is crucial to complete an incident report to document the event, assess the cause, and implement measures to prevent similar incidents. This helps ensure client safety and continuous quality improvement.

Choice D rationale

When a client's visitor becomes dizzy and faints in the client's room, an incident report should be completed to document the occurrence and initiate an investigation into the cause. This helps in providing appropriate care and preventing future incidents.

Choice E rationale

A client's inability to afford recommended physical therapy is an important issue but does not typically require an incident report. This situation should be addressed through social services or financial counseling to find a solution.

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Correct Answer is C

Explanation

Choice A rationale

A repressed grief response, where an individual avoids expressing their grief, is considered delayed grief, not exaggerated grief. This can manifest as physical symptoms or psychological issues later on.

Choice B rationale

Grief that begins following a terminal diagnosis is anticipatory grief, which is a normal response as individuals begin to process the impending loss. It prepares them emotionally for the eventual death.

Choice C rationale

Exaggerated grief involves intense, prolonged, and often harmful reactions such as self-destructive behaviors. This type of grief can significantly impair a person's ability to function and may require professional intervention.

Choice D rationale

A grief response triggered by a secondary loss (e.g., loss of job or home) is known as cumulative grief. While it complicates the grieving process, it does not inherently lead to the exaggerated, self-destructive behaviors seen in exaggerated grief.

A. A. Assess the pain level of a client who has received acetaminophen. B. Check a client's peripheral IV site for redness or swelling. C. Measure the intake and output of a client who has received furosemide. D. Reinforce teaching with a client about crutch-gait walking.

Correct Answer is C

Explanation

Choice A rationale

Assessing pain levels is a nursing task requiring clinical judgment, which is beyond the scope of an assistive personnel's duties.

Choice B rationale

Checking an IV site for redness or swelling also requires clinical assessment skills, which are tasks for the nurse.

Choice C rationale

Measuring intake and output is a routine task that can be safely delegated to an assistive personnel. It involves straightforward measurement and recording.

Choice D rationale

Reinforcing teaching about crutch-gait walking requires specific patient education, which falls under the nurse's responsibilities.

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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

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Explanation

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Correct Answer is C

Explanation

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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.)