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 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 B
Answer and explanation
The correct answer is Choice B.
Choice A rationale
Speculating about the cause of the fall ("probably urinated on the floor") is unprofessional and lacks factual basis. Charting should be objective and based on observed facts, not assumptions.
Choice B rationale
Documenting objective observations, such as finding the patient on the floor with the urinal nearby, provides a factual account of the incident without making assumptions or assigning blame. This allows for a more accurate analysis of potential contributing factors.
Choice C rationale
Commenting on the nurse assistant's work habits ("always took her time") is subjective, irrelevant to the fall incident itself, and unprofessional. Charting should focus on the patient and the event.
Choice D rationale
Describing the patient as "grouchy and inappropriate" is judgmental, subjective, and does not contribute to an understanding of the fall. Such personal opinions are inappropriate for medical documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Maslow's hierarchy of needs is a framework that prioritizes human needs in a hierarchical order, starting with physiological needs, followed by safety, love and belonging, esteem, and self-actualization. In the planning phase of nursing, this framework helps nurses to establish priorities of care by addressing the most basic and urgent needs first before moving to higher-level needs.
Choice B rationale
Piaget's cognitive developmental theory describes the stages of intellectual development in children and adolescents. While understanding cognitive development can inform nursing care, it is not the primary framework used for establishing priorities of care during the planning phase.
Choice C rationale
Erikson's stages of psychosocial development outline the social and emotional challenges individuals face across the lifespan. While relevant to understanding a client's psychosocial well-being, it is not the primary framework for prioritizing immediate nursing interventions in the planning phase.
Choice D rationale
Kohlberg's stages of moral development describe the progression of moral reasoning. While understanding a client's moral perspective can be relevant in certain situations, it is not the central framework used for establishing the priorities of physiological and safety needs in the nursing care plan. .
Correct Answer is A
Explanation
Choice A rationale
Reading back the order ensures accuracy and allows the physician to immediately correct any misheard or misinterpreted information. This step is crucial for patient safety as it verifies the details of the medication order before it is implemented.
Choice B rationale
While double-checking with another nurse is a good practice, the immediate priority after receiving a telephone order is to confirm the order directly with the prescriber to avoid any initial misunderstanding.
Choice C rationale
Authorizing the order with the pharmacy occurs after the order has been received and verified. The pharmacy then prepares and dispenses the medication based on the confirmed order.
Choice D rationale
Withholding the medication could delay necessary treatment. The priority is to verify the order promptly and then proceed with safe administration. Many institutions allow for a limited time frame for the written order to follow a telephone order.
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.