A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?
An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom.
An assistive personnel applies physical restraints on a client who is aggressive
An assistive personnel tells the provider that a client is making other clients feel unsafe.
An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm.
The Correct Answer is B
A. An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom: Reapplying a soft limb restraint in itself does not necessarily require an incident report. However, the application must follow proper protocols, and the nurse should ensure that the assistive personnel are trained and following the correct procedures.
B. An assistive personnel applies physical restraints on a client who is aggressive: Physical restraints should only be applied with a physician's order and in accordance with facility policies. If restraints are applied without proper authorization or protocol, an incident report must be completed.
C. An assistive personnel tells the provider that a client is making other clients feel unsafe: Reporting concerns to the provider about a client's behavior is part of proper communication and does not require an incident report.
D. An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm: This is an appropriate and necessary intervention for a client at risk of self-harm. It does not require an incident report, as the staff member is performing their duty to ensure the safety of the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","H"]
Explanation
Rationale for correct choices:
- Ask the client if they have been hit, slapped, or kicked within the past year: This question is specific and nonjudgmental, helping the client disclose abusive behaviors without feeling pressured. It's important for identifying signs of abuse that may not be immediately obvious.
- Ask the client to clarify the circumstances of their injuries: Clarifying the circumstances of the injuries helps the nurse assess the situation and detect any discrepancies in the explanation that may suggest abuse. It can also guide the next steps in care and safety planning.
- Discuss with the client the factors that precipitate violence: Identifying triggers and patterns of violence empowers the client to recognize and avoid dangerous situations, and to plan for their safety moving forward.
Rationale for incorrect choices:
- Interview the client with another nurse present: The primary goal during is to establish a private and trusting environment where the client feels safe to disclose. The presence of another person can make a client feel less comfortable and less likely to speak openly about sensitive issues like intimate partner violence.
- Ask questions in different ways until the client provides an answer: Repeating or rephrasing questions multiple times could make the client feel pressured or coerced, which may hinder trust and open communication. It’s important to respect their pace and comfort level.
- Refrain from asking the client if they are afraid of their partner: Fear of the partner is a crucial indicator of abuse, and not asking about it may prevent the client from disclosing important information. Acknowledging fear helps assess the level of risk and urgency.
- Assure the client that their medical team feels sympathy for their injuries and disapproval for the person responsible for inflicting them: While empathy is important, making value judgments about the abuser can undermine the client's trust, making them feel judged or unsupported in their decisions.
- Inform the client that they should have fought back: Telling the client what they "should have done" may inadvertently place blame on them and discourage further disclosures. It’s vital to maintain a supportive, nonjudgmental stance to ensure the client feels safe.
Correct Answer is D
Explanation
A. The client does not recognize their partner: While this is concerning, it is a common symptom of Alzheimer's disease as it progresses. However, it is not immediately life-threatening or a direct risk to the client’s safety.
B. The client places their shoes on the wrong feet: This is a typical manifestation of cognitive decline in Alzheimer's disease. While it may affect the client's independence, it is not an urgent issue that requires immediate intervention compared to other symptoms.
C. The client is unable to remember their personal history: Memory loss, especially related to personal history, is a hallmark symptom of Alzheimer's disease. Although it affects the client's cognitive function, it is not a crisis situation requiring priority intervention.
D. The client engages in wandering: Wandering is the priority concern in this scenario. It poses a significant safety risk, as the client may become lost, confused, or injured. Ensuring the client's safety by addressing wandering behavior is essential in managing Alzheimer's disease.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.