A home care nurse is caring for a quadriplegic client who needs ...

[meagbuch]

A home care nurse is caring for a quadriplegic client who needs regular position changes and back massages. A gentleman identifying himself as a family friend inquires if he can be of any help to the family. What should be the nurse's response be?
 
  A) The nurse should ask the gentleman to talk to the family directly.
  B) The nurse should invite the gentleman to learn the caring techniques.
  C) The nurse should state that the family does not need any help.
  D) The nurse should refer the gentleman to the local social worker.

Question 2

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room when she hears the client calling for help. She finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment.
 
  The nurse informs the physician and completes the incident report. Which of the following statements should the nurse document in the incident report?
 
  A) The client was trying to lower the side rails.
  B) The client was found lying on the floor.
  C) The client was trying to get out of the bed.
  D) The client was not aware that he had fallen.

[Jossy]

Answer to Question 1

Ans: A
The nurse should ask the gentleman to talk to the family directly. Revealing information about the client's care is a violation of the client's privacy. The nurse should not invite the gentleman for a learning session because it would be a breach of the client's right to privacy. Referring him to a social worker is not an appropriate choice.

Answer to Question 2

Ans: B
An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. All of the details given in the incident report should be accurate and not assumed. Accurate and detailed documentation helps to prove that the nurse acted reasonably or appropriately in the circumstance. The nurse should document that the client was found lying on the floor. The other statements are assumptions and should not be included in the incident report.

[meagbuch]

Excellent

[Sarahjh]

TYSM