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 B
Explanation
Choice A rationale
Producing clinical pathways is an application of informatics, where data and technology are used to standardize care processes for specific conditions. However, this is a specific outcome of informatics rather than the overarching definition of the field itself. Informatics encompasses a broader scope than just the creation of these pathways.
Choice B rationale
Informatics in healthcare is fundamentally about managing knowledge. This involves the acquisition, storage, retrieval, analysis, and dissemination of information to improve decision-making, enhance patient care, and advance healthcare practice. Technology serves as the tool to facilitate this knowledge management.
Choice C rationale
While effective use of informatics tools might indirectly contribute to a more efficient workflow and potentially reduce some stressors, preventing burnout is not the primary definition of informatics. Burnout is a complex issue influenced by various factors beyond information and technology.
Choice D rationale
Providing a safe place to administer care is a fundamental goal of the entire healthcare system, encompassing many aspects beyond informatics. While informatics can contribute to safety through improved communication and access to information, it is not the defining purpose of the field itself.
Correct Answer is B
Explanation
Choice A rationale
While documentation can be reviewed by providers, its primary purpose is not to monitor nurses' performance. Monitoring occurs through various quality assurance processes, and documentation serves a broader range of functions beyond individual nurse oversight.
Choice B rationale
Documentation acts as a central communication hub for all members of the healthcare team, including physicians, nurses, therapists, and other specialists. It ensures continuity of care by providing a shared understanding of the client's condition, treatments, and responses, facilitating informed decision-making and collaboration.
Choice C rationale
Although documentation can be used for audits, such as financial or quality audits, this is not its primary purpose. The main goal of documentation is to provide a comprehensive record of patient care for effective communication and continuity.
Choice D rationale
While accurate documentation supports billing and reimbursement processes from various payers, including government entities, this is a secondary outcome. The primary aim of documentation is to ensure high-quality patient care through clear and comprehensive information sharing.
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