A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this client?
A) Briefly leave the client in order to call the primary physician to assess the client's condition.
B) Order x-rays or CT scans for the client, as needed.
C) Document the incident, assessment, and interventions in the client's medical record.
D) Do not file an event report unless the client is seriously injured in the fall.
Ans: C
The nurse is responsible for documenting the incident in the client's record. Assess the patient immediately and provide appropriate care and interventions based on client status, and ensure prompt follow-through for any physician orders for diagnostic tests. An event report should be filed in the case of a fall, as per facility policy.
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