The nurse enters a client's room and finds them on the floor. What documentation is most appropriate?
"The client fell out of bed and slid to the floor. The floor around the bed was wet."
"Client given incorrect medications, resulting in dizziness and a fall,"
"The client did not call for assistance and fell onto the floor."
"Upon entering room, the client was seen lying on the floor."
The Correct Answer is D
Rationale:
A. "The client fell out of bed and slid to the floor. The floor around the bed was wet.": This includes assumptions about how the fall occurred and contributing factors, which may not be verified. Documentation should be objective and based on direct observation rather than interpretation.
B. "Client given incorrect medications, resulting in dizziness and a fall,": This statement assigns blame and makes a causal judgment. Nursing documentation should remain factual and avoid speculation about causes or errors unless confirmed through incident reporting.
C. "The client did not call for assistance and fell onto the floor.": This also implies fault on the part of the client, which is subjective. Objective documentation should focus on what the nurse observed rather than attributing cause.
D. "Upon entering room, the client was seen lying on the floor.": This statement is factual and objective, documenting only what the nurse directly observed. It avoids assumptions, blame, or speculation, making it the most appropriate choice for accurate and professional documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Preparing written clinical assignments without concealing the clients identifying information: Sharing identifiable client information in assignments without consent constitutes a breach of privacy and violates HIPAA regulations.
B. A student nurse, who assisted with the delivery, being photographed with a client's new baby: Taking photographs of a patient or newborn without consent is a violation of privacy and confidentiality, even if the student was involved in care.
C. Informing the client's nurse that the patient has been diagnosed with HIV/AIDS: Sharing relevant medical information with another healthcare provider involved in the patient’s care is appropriate and necessary for safe, coordinated treatment.
D. Discussing a client's prognosis and length of stay with the client's boss: Sharing private health information with someone not involved in care, such as an employer, is a violation of patient privacy and confidentiality.
Correct Answer is D
Explanation
Rationale:
A. Beneficence: Beneficence involves promoting the well-being of the client and taking actions that benefit them. While the nurse’s actions may also benefit the client, the decision is primarily focused on avoiding harm.
B. Veracity: Veracity refers to truth-telling and honesty in communication. This principle does not directly relate to the decision to delay turning due to pain.
C. Advocacy: Advocacy involves supporting the client’s rights and needs. While the nurse is attentive to the client’s comfort, the ethical decision in this scenario is based on avoiding harm rather than advocating per se.
D. Non-maleficence: Non-maleficence is the principle of “do no harm.” By choosing not to turn the client to prevent causing severe pain, the nurse is adhering to this principle, prioritizing the avoidance of harm over routine interventions.
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