The nurse reviews the client's test results.

Exhibits

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A. Completing an incident report is required for tracking falls and improving safety measures, but it is not the first priority. The nurse must first assess the client to determine if immediate medical intervention is needed. Delay in assessment could lead to unrecognized injuries or complications. Incident reports are also not part of the medical record and should be completed after client care. Ensuring client stability always takes precedence over documentation.
B. Measuring vital signs is the priority because it helps identify any immediate complications from the fall, such as hypotension, pain, or neurological impairment. A sudden drop in blood pressure could indicate shock, while tachycardia may suggest distress or injury. Checking for changes in mental status, pain levels, and potential fractures ensures timely intervention. If abnormalities are found, further evaluation or treatment can be initiated promptly. Early assessment prevents worsening conditions and guides further actions.
C. Documenting the fall in the client's medical record is necessary for continuity of care but should be done after assessing and stabilizing the client. Medical documentation includes details about the fall, findings from the assessment, and any interventions provided. However, delaying assessment to document first could result in missed critical signs of injury. Proper documentation supports quality care but is secondary to ensuring the client’s immediate well-being. The nurse should prioritize physical assessment before recording the incident.
D. Notifying the provider is important, especially if the client has sustained injuries, is in pain, or has abnormal vital signs. However, calling the provider before performing an assessment can lead to incomplete or inaccurate reporting. The provider will need specific details about the client's condition, including neurological status, hemodynamics, and any visible injuries. Conducting an assessment first ensures that the provider receives the most relevant and useful information. Immediate assessment allows for timely intervention and prevents unnecessary delays in care.

A. "I will get you information about some head-covering options." This response is supportive and addresses the client's concerns about hair loss in a practical way. Providing information about head coverings, such as hats, scarves, or wigs, can help the client feel more prepared and empowered to manage this aspect of their treatment.
B. "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing the client's concerns may make them feel invalidated. Hair loss can be a significant emotional issue for many clients undergoing chemotherapy, and it’s important to address their feelings and provide support.
C. "Let's discuss this when we have more time." Postponing the conversation may leave the client feeling anxious or unsupported. Clients may need immediate reassurance and resources regarding their concerns, so it is essential to address it in a timely manner.
D. "I can't imagine how difficult it would be to lose my hair." Expressing empathy is important, but shifting the focus to the nurse's feelings rather than addressing the client's concerns is not helpful. It is more beneficial to provide practical support and resources to help the client cope with potential hair loss.