A nurse identifies a nursing diagnosis of Risk for falls when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change

Question

What is the nurse's priority action when evaluating the patient's plan of care?
a. Counsel the nursing assistive personnel on duty when the patient fell.
b. Identify factors interfering with goal achievement.
c. Remove the fall risk sign from the patient's door because the patient has suffered a fall.
d. Request that the more experienced charge nurse complete the documentation about the fall.

Answer 1

ANS: B
After a change in the patient's condition or an untoward event, the nurse attempts to identify factors interfering with goal achievement. In this case, the nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistant; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation.