A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?
Use objective terminology when documenting
Wait at least 12 hours to report the occurrence
Omit the name of the individuals involved
Document completion of the report in the client’s medical record
The Correct Answer is A
Choice A reason: This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
Choice B reason: This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
Choice C reason: This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
Choice D reason: This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The hospital supervisor is not the first person to notify, as they are not directly responsible for the unit or the staff. The hospital supervisor is usually a senior nurse who oversees the operations of the entire hospital or a specific shift. They may be involved in the later stages of the reporting process, but not as the initial contact.
Choice B reason: The charge nurse is the first person to notify, as they are the immediate supervisor of the unit and the staff. The charge nurse is usually an experienced nurse who coordinates the care and activities of the unit, assigns tasks, and provides guidance and support to the staff. They have the authority and responsibility to address the situation and take appropriate actions.
Choice C reason: The chief nursing officer is not the first person to notify, as they are not directly involved in the unit or the staff. The chief nursing officer is usually the highestranking nurse in the organization, who oversees the nursing practice, quality, and education across the entire system. They may be informed of the situation by the unit director or the hospital supervisor, but not as the initial contact.
Choice D reason: The unit director is not the first person to notify, as they are not directly available on the unit or the staff. The unit director is usually a nurse manager who oversees the administrative and financial aspects of the unit, such as budgeting, staffing, and evaluation. They may be notified of the situation by the charge nurse or the hospital supervisor, but not as the initial contact.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because psychiatric history is not the most urgent assessment to make for a client who reports feeling depressed and anxious. Psychiatric history can provide valuable information about the client's diagnosis, treatment, and response, but it is not a priority over the client's safety and wellbeing.
Choice B reason: This statement is correct because suicide risk is the most urgent assessment to make for a client who reports feeling depressed and anxious. Suicide risk can indicate the client's level of hopelessness, despair, and intent to harm themselves. The nurse should assess the client's suicidal thoughts, plans, means, and access, and implement appropriate interventions to prevent self harm or suicide.
Choice C reason: This statement is incorrect because support systems are not the most urgent assessment to make for a client who reports feeling depressed and anxious. Support systems can provide emotional, social, and practical assistance to the client, but they are not a priority over the client's safety and wellbeing.
Choice D reason: This statement is incorrect because coping abilities are not the most urgent assessment to make for a client who reports feeling depressed and anxious. Coping abilities can reflect the client's strategies and skills to manage their stress and emotions, but they are not a priority over the client's safety and wellbeing.
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