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."
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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Related Questions
Correct Answer is D
Explanation
The correct answer is D.
Time of last pain medication. The nurse should include information that is relevant and essential for the continuity of care of the client, such as current assessment findings, interventions performed, response to treatment, and pending tests or procedures. The time of last pain medication is important to report because it affects the client's comfort level and mobility, and it helps the oncoming nurse plan when to administer the next dose of analgesia.
The steps required for dressing change are not necessary to report because they are usually standardized and documented in the policy manual or the care plan. The admission vital signs are not relevant to report because they do not reflect the client's current status. The preferred bath time is not essential to report because it can be obtained from the client or the chart.
Correct Answer is C
Explanation
The correct answer is C. Paranoid schizophrenia is a type of schizophrenia that involves delusions of persecution or conspiracy. The nurse should use therapeutic communication techniquesto empathize with the client's feelings and encourage them to express their thoughts without challenging or reinforcing their delusions. Therefore, stating that this must be very frightening for them and inviting them to talk more about it is an appropriate response that can help reduce anxiety and build trust. The other statements are not helpful or may be harmful. Asking why or what questions may imply doubt or disbelief in the client'sreality and provoke defensiveness or hostility. Contradicting or correcting the client's delusions may also increase their suspicion and resistance to treatment.
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