The nurse enters the client's room and finds the client sitting on the floor beside the bed. The nurse asks the client if he fell, and the client denies a fall. Which of the following actions should the nurse take?

Question

1. Leave the client on the floor and get another nurse to witness the event.
2. Assess the client and complete an incident report.
3. Document in the chart that the client fell out of bed.
4. Accept the client's statement that she did not fall.

Answer 1

2
Rationale 1: The nurse should first assess the client and provide any needed care. Once the client is cared for, the nurse should complete an incident report, because the client was found on the floor. While it is possible the client chose to sit on the floor, it is not likely; an incident report would be the safest action to take, and will cause no harm if the client indeed chose to sit on the floor. Answer option 1 is incorrect because it requires the client to remain on the floor, possibly injured, and there is no need for a witness. Option 3 is incorrect because the nurse should document objectively, and did not witness the client fall out of bed. The correct wording would be "Client found sitting on floor, denies falling." Option 4 is not acceptable, because of the high likelihood that the client might have fallen. Completing an incident report will not cause a problem if the client did not actually fall, and can be important if problems arise later.