The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident?
The patient is grouchy and inappropriate, always causing trouble for the nurses.
The patient’s nurse assistant always took her time to answer his call lights.
The patient probably urinated on the floor and slipped on the wet floor.
The patient was found on the floor and his urinal was on the floor next to him.
The Correct Answer is D
Choice A reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is subjective, biased, and disrespectful. The nurse should not make judgments or assumptions about the patient's personality or behavior, but rather report the facts and observations of the situation.
Choice B reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is irrelevant, speculative, and accusatory. The nurse should not blame or criticize the nurse assistant's performance, but rather focus on the patient's condition and the actions taken to prevent or manage the fall.
Choice C reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is uncertain, hypothetical, and unprofessional. The nurse should not use words like "probably" or "maybe" that indicate a lack of clarity or certainty, but rather state the facts and evidence of the situation.
Choice D reason: This is an appropriate statement for the nurse to include in the description of the incident because it is objective, factual, and concise. The nurse should report the patient's location, status, and environment at the time of the fall, and the possible cause or contributing factors of the fall.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Chronic pain is not a type of pain, but a duration of pain. Chronic pain is pain that lasts longer than six months, regardless of the cause or location. It can affect the patient's physical and mental health, as well as their quality of life.
Choice B reason: This is incorrect. Psychogenic pain is not a type of pain, but a source of pain. Psychogenic pain is pain that is caused or influenced by psychological factors, such as stress, anxiety, depression, or trauma. It can affect any part of the body, but it is not related to the patient's heart attack.
Choice C reason: This is correct. Referred pain is pain that is felt in a different location from the actual source of pain. It occurs when the nerve fibers from different parts of the body converge in the spinal cord or brain. The patient's pain is down his left arm rather than in his chest because the heart and the arm share some nerve pathways.
Choice D reason: This is incorrect. Peripheral pain is pain that is caused by damage or dysfunction of the peripheral nervous system, which consists of the nerves outside the brain and spinal cord. It can cause sensations of numbness, tingling, burning, or shooting pain in the affected area. It is not related to the patient's heart attack.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because health-seeking behaviors related to expressed desire for better sleep is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Health-seeking behaviors are actions that a person takes to improve their health and well-being. However, this is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.
Choice B reason: This is an incorrect choice because impaired bed mobility related to presence of CPAP mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Impaired bed mobility is the limitation of the patient's ability to move in bed. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Choice C reason: This is an incorrect choice because risk for impaired skin integrity related to tight-fitting mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for impaired skin integrity is the potential for the patient's skin to be damaged or broken. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Choice D reason: This is the correct choice because risk for powerlessness related to inability to breathe regularly during sleep is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for powerlessness is the potential for the patient to feel a loss of control or self-efficacy. This is the most urgent and life-threatening problem for the patient, as it can result in psychological distress, anxiety, depression, or hopelessness.
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