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 ["B","D"]
Explanation
Choice A reason: This is incorrect. Tramadol is not a nonsteroidal anti-inflammatory medication. Tramadol is an opioid analgesic medication that works by binding to opioid receptors in the brain and spinal cord. It can relieve moderate to severe pain, but it does not have any anti-inflammatory effect.
Choice B reason: This is correct. Aspirin is a nonsteroidal anti-inflammatory medication. Aspirin is a salicylate medication that works by inhibiting the enzyme cyclooxygenase, which is involved in the synthesis of prostaglandins. Prostaglandins are chemical messengers that mediate inflammation, pain, and fever. Aspirin can reduce inflammation, pain, and fever, as well as prevent blood clots and protect the heart.
Choice C reason: This is incorrect. Acetaminophen is not a nonsteroidal anti-inflammatory medication. Acetaminophen is a para-aminophenol medication that works by inhibiting the enzyme cyclooxygenase in the central nervous system, but not in the peripheral tissues. It can reduce pain and fever, but it does not have any anti-inflammatory effect.
Choice D reason: This is correct. Ibuprofen is a nonsteroidal anti-inflammatory medication. Ibuprofen is a propionic acid medication that works by inhibiting the enzyme cyclooxygenase, which is involved in the synthesis of prostaglandins. Prostaglandins are chemical messengers that mediate inflammation, pain, and fever. Ibuprofen can reduce inflammation, pain, and fever, as well as treat arthritis and menstrual cramps.
Choice E reason: This is incorrect. Codeine is not a nonsteroidal anti-inflammatory medication. Codeine is an opioid analgesic medication that works by binding to opioid receptors in the brain and spinal cord. It can relieve mild to moderate pain, but it does not have any anti-inflammatory effect.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because gently trimming the patient’s toenails after soaking the feet in warm soapy water is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Trimming the toenails can be risky for the diabetic patient, as it can cause bleeding, infection, or injury to the nail bed or surrounding skin. The nurse should avoid cutting the toenails of the diabetic patient, unless instructed by a podiatrist.
Choice B reason: This is an incorrect choice because using a pumice stone to smooth roughened areas of skin on the patient’s feet is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. A pumice stone is a porous rock that can be used to exfoliate the skin and remove dead cells. However, it can also damage the skin and cause abrasions, irritation, or infection. The nurse should be careful when using a pumice stone on the diabetic patient, and avoid rubbing too hard or too often.
Choice C reason: This is an incorrect choice because liberally applying lotion to the patient's feet especially between the toes is not the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Applying lotion to the feet can help to moisturize and soften the skin, but it can also create a moist environment that can promote fungal growth and infection. The nurse should apply lotion sparingly to the feet of the diabetic patient, and avoid applying it between the toes.
Choice D reason: This is the correct choice because obtaining a consultation for a podiatrist to assess the feet and provide nail care is the best intervention of the nurse for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. A podiatrist is a specialist who can diagnose and treat foot problems, such as nail disorders, skin conditions, or infections. The podiatrist can safely and effectively trim the toenails of the diabetic patient, and provide education and advice on foot care and prevention of complications. The nurse should refer the diabetic patient to a podiatrist at least once a year, or more often if needed.
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