Nokea
One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client?
- A. Incident report completed.'
- B. the reason the client was unattended
- C. the vital signs and assessment of the client
- D. location of the incident report
Correct Answer: C
Rationale: After a fall, recording vital signs and assessment in nursing notes is most needed, providing a clinical picture post-incident like stable pulse and no fractures for care and legal purposes. Noting the report's completion or location is administrative, and explaining absence justifies but doesn't document health status. This ensures comprehensive client-focused documentation.
You may also like to solve these questions
What can you expect from Marianne, who is currently at the ONSET stage of fever?
- A. Hot, flushed skin
- B. Increase thirst
- C. Convulsion
- D. Pale,cold skin
Correct Answer: D
Rationale: Fever's onset (chill phase) features vasoconstriction e.g., pale, cold skin as the body raises its setpoint. Hot, flushed skin (flush phase), thirst (later), or convulsions (hyperpyrexia) follow. Nurses expect this initial response e.g., shivering in Marianne, guiding warming measures, per fever physiology.
The nurse asked an aide to check Mr. Gary's vitals. This is an example of?
- A. Delegation
- B. Responsibility
- C. Malpractice
- D. Health policy
Correct Answer: A
Rationale: Asking an aide for vitals is delegation (A) task assignment, per definition. Responsibility (B) duty, malpractice (C) breach, policy (D) rules not delegation-specific. A fits the nurse's supervised task for Mr. Gary, making it correct.
A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending:
- A. Pulmonary egophony
- B. Amniotic fluid embolism
- C. Anaphylaxis
- D. Bronchospasm
Correct Answer: C
Rationale: Sudden breathing difficulty, weakness, and nausea during antibiotic administration suggest a severe allergic reaction, known as anaphylaxis. This life-threatening condition involves systemic histamine release, causing airway constriction, hypotension, and gastrointestinal distress. Pulmonary egophony relates to lung sound changes, not systemic symptoms. Amniotic fluid embolism presents with cardiovascular collapse and bleeding, not primarily nausea. Bronchospasm is airway narrowing but lacks the broader symptoms here. Immediate recognition of anaphylaxis prompts epinephrine administration and airway support, critical for maternal and fetal survival in labor.
A nurse must possess several characteristics to be successful in this profession. Secondary to critical thinking skills, which is of great value?
- A. Good teamwork and team-building skills
- B. A master's degree
- C. The ability to delegate responsibilities
- D. Advocating for the client at all times
Correct Answer: D
Rationale: Beyond critical thinking, advocating for the client at all times is a cornerstone of nursing success, reflecting the profession's core commitment to patient welfare. This involves ensuring clients' needs, rights, and preferences are prioritized in all care decisions, fostering trust and empowerment. Good teamwork and team-building skills are valuable for collaboration but are learned and applied contextually, not as intrinsic as advocacy. A master's degree enhances expertise but isn't required for foundational success, as many nurses excel with lesser credentials. Delegation is a skill that supports efficiency, yet it's secondary to the nurse's role as a client advocate. Advocacy drives nursing's caring ethos, addressing health needs across diverse settings and populations, making it a vital characteristic that complements critical thinking in achieving optimal outcomes and upholding professional integrity.
A nurse uses an institution's procedure manual to confirm how to insert a nasogastric tube. The level of critical thinking the nurse is using is:
- A. Basic critical thinking
- B. Commitment
- C. Complex critical thinking
- D. Scientific method
Correct Answer: A
Rationale: Basic critical thinking involves following established guidelines or procedures, like using a manual for nasogastric tube insertion, typical for novices relying on concrete rules. The nurse here seeks confirmation, indicating dependence on external standards rather than independent judgment. Commitment reflects decisive action based on internalized reasoning, not manual reliance. Complex critical thinking analyzes and adapts procedures (e.g., modifying technique for patient anatomy), requiring experience beyond rote steps. The scientific method tests hypotheses, not applicable to routine protocol checks. Basic critical thinking suits this scenario, as the nurse applies learned steps without deviation, a foundational level ensuring safe practice while building toward higher-order skills in dynamic clinical settings.