A nurse identifies a nursing diagnosis of Risk for falls when ...

[penza]

A nurse identifies a nursing diagnosis of Risk for falls when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change.
 
  What is the nurse's priority action when evaluating the patient's plan of care?
  a. Counsel the nursing assistive personnel on duty when the patient fell.
  b. Identify factors interfering with goal achievement.
  c. Remove the fall risk sign from the patient's door because the patient has suffered a fall.
  d. Request that the more experienced charge nurse complete the documentation about the fall.

Question 2

Which of these options is a patient outcome indicating positive progress toward resolving the nursing diagnosis of Acute confusion?
 
  a. Side rails are up with bed alarm activated.
  b. Patient denies pain while ambulating with assistance.
  c. Patient wanders halls at night.
  d. Patient correctly states names of family members in the room.

[frankwu0507]

Answer to Question 1

ANS: B
After a change in the patient's condition or an untoward event, the nurse attempts to identify factors interfering with goal achievement. In this case, the nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistant; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation.

Answer to Question 2

ANS: D
The identified nursing diagnosis is Acute confusion. The outcome for this diagnosis would address a decrease or absence of confusion. One sign of orientation is when a patient responds to questions appropriately. Thus, one possible sign that a patient's confusion is improving is seen when a patient can correctly state the names of family members in the room. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient's denying pain indicates positive progress toward resolving a diagnosis of Acute or Chronic pain. The patient's wandering the halls is a sign of confusion.

[penza]

Excellent

[peter]

TYSM