A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

The client fell because the assistive personnel did not place nonskid slippers on the client."

The client does not appear to have any injuries resulting from the fall."

"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'."

"An incident report has been completed and sent to risk management."

Answer and Explanation

The Correct Answer is C

The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.

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Correct Answer is A

Explanation

The correct answer is A. A client who has a spinal cord injury requires an interprofessional approach to care that involves multiple disciplines such as physical therapy, occupational therapy, social work, and rehabilitation nursing. The other clients have less complex needs that can be managed by one or two disciplines.

A. Call the supervisor to ask for another nurse. B. Remove the nurse from the client care area. C. Assign clients to the remaining staff. D. Document objective findings about the situation.

Correct Answer is B

Explanation

Explanation: The first action that the charge nurse should take is to remove the nurse from the client care area, as this will protect the clients from potential harm and prevent further impairment of the nurse. The charge nurse should then call the supervisor, assign clients to other staff members, and document objective findings about the situation.

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A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Nursing Test Bank

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