The registered nurse (RN) hears a client calling out for help. The RN hurries down the hallway to the client's room and finds the client lying on the floor. The RN performs a thorough assessment and assists the client back to bed
The physician is notified of the incident, and the nurse com-pletes an incident report. Which of the following would the RN document on the incident report? 1. The client fell out of bed.
2. The client climbed over the side rails.
3. The client was found lying on the floor.
4. The client became restless and tried to get out of bed.
3
Rationale: The incident report should contain the client's name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. "The client was found lying on the floor" is the only option that de-scribes the facts as observed by the nurse. "The client fell out of bed," "the client climbed over the side rails," and "the client became restless and tried to get out of bed" are interpretations of the situation and are not factual data as observed by the nurse.
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A) a diet high in fat. B) a history of current or past alcohol use. C) current nicotine use. D) a diet high in carbohydrates.
Which nursing action is inappropriate when providing the client with a hygienic and comfortable environment?
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a. the right color, and the right manufacturer b. the right generic substitute, and the right-size tablet or capsule c. the right route, and the right time d. the right name, and the right room
The nurse is conducting a group education session for patients who have been diagnosed with depression. The nurse evaluates the education as effective when a patient makes which comments about the cause of depression? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. "Depression has many causes; they could include environmental as well as brain-based disorders." 2. "Depression includes impaired relationships and is also an inherited illness." 3. "We really don't know what causes depression; it has not been studied very much." 4. "Depression results from unresolved conflicts in your childhood." 5. "Depression results from parents who are cold and distant and don't really care about their children."