A client is admitted with symptoms of psychosis. The nurse hurries to the client's room when she hears the client calling for help. She finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment
The nurse informs the physician and completes the incident report. Which of the following statements should the nurse document in the incident report?
A) The client was trying to lower the side rails.
B) The client was found lying on the floor.
C) The client was trying to get out of the bed.
D) The client was not aware that he had fallen.
Ans: B
An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. All of the details given in the incident report should be accurate and not assumed. Accurate and detailed documentation helps to prove that the nurse acted reasonably or appropriately in the circumstance. The nurse should document that the client was found lying on the floor. The other statements are assumptions and should not be included in the incident report.
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