The nurse responds to a voice calling out from a room on the nursing unit. Upon entering the room, the nurse sees a patient lying on the floor near the foot of the bed. After attending to the patient and notifying the HCP, which notation would be most appropriate to record on the incident occurrence report?

Patient found lying on floor at foot of the bed.

Patient was rushing to the bathroom to avoid incontinence.

Patient fell while walking to the bathroom.

Patient states nursing staff did not respond to the call bell.

Answer and Explanation

The Correct Answer is A

A.   This statement is the most appropriate for an incident occurrence report. It provides a factual, objective description of what was observed without inferring causes or making assumptions about the patient’s actions. Clear documentation is critical in incident reports for accuracy and potential follow-up.
B.   This statement includes assumptions about the patient's motivations and actions. It is speculative and not based on direct observation. Incident reports should avoid subjective interpretations and focus on what can be objectively verified.
C.   Although this statement describes a potential scenario, it assumes that the patient was walking to the bathroom and that this was the cause of the fall. Since the nurse did not witness the event, this could be misleading and should be avoided in an incident report.
D.   While documenting patient statements can be important, this particular comment is subjective and does not provide an objective account of the incident. It could also lead to potential blame without verifying the accuracy of the statement, which could complicate the report.

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Correct Answer is B

Explanation

A. Battery refers to the intentional and unlawful physical contact with another person without their consent. In this scenario, the nurse did not intend to harm the patient; the action was accidental. Therefore, battery would not apply here.
B. Malpractice is a type of negligence that occurs when a healthcare professional fails to provide the standard of care that a reasonably competent nurse would provide in similar circumstances. Administering the wrong medication is a breach of duty, and if this mistake leads to harm (like an allergic reaction), the nurse can be held liable for malpractice.
C. Abuse generally refers to intentional harm or mistreatment of a patient, often involving physical or emotional harm. Since the nurse's actions were accidental and not intended to cause harm, this would not constitute abuse.
D. Assault involves the threat or attempt to cause physical harm to another person, creating a fear of imminent harm. Since the nurse did not intend to threaten or harm the patient, and the incident was not a threat, this does not fit the definition of assault.

A. "Monitor your child's temperature daily." B. "Offer fluids to your child multiple times every day." C. "Restrict outdoor play activity to 1 hour per day." D. "Apply cold compresses when your child expresses pain."

Correct Answer is B

Explanation

A. Monitoring temperature is also important, but it does not directly prevent a crisis.
B. Hydration is critical for children with sickle cell anemia, as it helps prevent sickle cell crises by promoting adequate blood flow and reducing blood viscosity. Encouraging frequent fluid intake is essential in managing the condition.
C. While it's important to monitor activity levels, outright restriction may not be necessary. Instead, children with sickle cell anemia should be encouraged to engage in age-appropriate activities while avoiding extreme temperatures and strenuous activities that could trigger a crisis. Balanced activity is essential for overall health and development.
D. Cold compresses are not typically recommended for managing pain during a sickle cell crisis. Instead, warmth is often preferred because it helps to relax muscles and improve blood flow. Cold can potentially exacerbate vasoconstriction, which is not beneficial for a child experiencing pain due to sickle cell disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

Correct Answer is B

Explanation

A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients in the nurse's assignment are stable. Which of the following legal terms applies to this situation?

A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY]

The RN overbears the nurses' aide speaking in a harsh tone to a client with early Alzheimer's memory loss. Which statement should the EN make to begin addressing this issue?

A nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10 mg/mL. Which of the following actions should the nurse take?

A nurse is uncharacteristically extroverted on today's shift, with an unsteady gait. The manager suspects that the nurse may be chemically Impaired. What is the manager's most appropriate action?

A nurse at a community clinic is reinforcing education for a newly licensed nurse about nursing advocacy. Which of the following actions should the nurse include as an example of nursing advocacy?

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?