A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

Administer acetaminophen to the client.

Complete an incident report.

Send the visitor to the risk management office.

Document the occurrence in the client's medical record.

Answer and Explanation

The Correct Answer is B

The correct answer is that the nurse should complete an incident report. An incident report is a formal record of an unexpected event that occurred in a healthcare facility. It is important for the nurse to document the details of the visitor's fall, including the date, time, location and any witnesses. This information can be used to identify and address any safety hazards that may have contributed to the fall.

Options a, c and d are not appropriate actions for the nurse to take in this situation. Administering acetaminophen to the client is not relevant to the visitor's fall. Sending the visitor to the risk management office and documenting the occurrence in the client's medical record are not necessary steps in this situation.

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Correct Answer is D

Explanation

The correct answer is choice d. Begin by testing the client while they are wearing glasses. Choice A rationale: Positioning the client 3.3 meters (10 feet) away from the chart is incorrect because the standard distance for the Snellen chart is 20 feet (6 meters). Choice B rationale: Documenting the largest line the client can read on the chart is part of the procedure, but it is not the initial action the nurse should take. The nurse must first ensure the client is wearing their glasses to get an accurate assessment. Choice C rationale: Instructing the client to begin the assessment with both eyes open is incorrect because visual acuity is typically tested one eye at a time, with the other eye covered. Choice D rationale: Beginning by testing the client while they are wearing glasses is correct because it provides the most accurate assessment of the client’s visual acuity in their usual state, ensuring the glasses are effectively correcting their vision

A. "I can refer you to hospice care, and they can help you at home." B. "You should discuss this with your family before making a decision." C. "Do you understand that, without treatment, you will die?" D. "Don't you think you are giving up too soon?"

Correct Answer is A

Explanation

The nurse should respect the client's autonomy and right to make decisions about their own care. Referring the client to hospice care is an appropriate response because it provides the client with support and care in their own home.

Options b, c, and d are not appropriate responses because they do not respect the client's autonomy.

Option b suggests that the client needs to discuss their decision with their family before making a decision, which may not be necessary or desired by the client.

Option c confronts the client with the reality of their illness in a potentially insensitive manner.

Option d suggests that the client is giving up too soon, which may not be an accurate or helpful assessment of the situation.

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A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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