The client climbed over the side rails of his bed and fell to the ...

[ghost!]

The client climbed over the side rails of his bed and fell to the floor, and an incident report needs to be completed. Which of the following is involved in the correct reporting of an incident?
 
  a. The nurse who witnessed the event completes the report.
  b. Details of the incident are subjectively described.
  c. An explanation of the possible cause for the incident is entered.
  d. A notation is included in the medical record that an incident report was prepared.

Question 2

Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: Client will lose 4.5 kg in 3 months?
 
  a. Interview the client to identify reasons why the goal was not met.
  b. Assess the client for possible physical reasons for failure to lose the weight.
  c. Discuss with the client whether he or she was truly motivated to lose the weight.
  d. Re-evaluate whether it was realistic for the client to lose 4.5 kg in three months.

[Kingjoffery]

Answer to Question 1

A
The nurse who witnessed the incident is the one who completes the report. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of the client. The incident report outlines circumstances that led to client injury or risk of injury, and falls is an example of when an incident report would need to be completed.
Details of the incident should be objectively, not subjectively, described on the incident report.
An explanation of the possible cause is not included in the incident report. The sequence of events is described objectively.
A notation that an incident report was written is not included in the medical record.

Answer to Question 2

A
When goals are not met, the nurse should identify the factors that interfere with goal achieve-ment.
The goal Assess the client for possible physical reasons for failure to lose the weight reflects an action to be taken after the interview to further determine how the care plan will be modified.
The goal Discuss with the client whether he or she was truly motivated to lose the weight re-flects an action to be taken after the interview to further determine how the care plan will be modified.
The goal Re-evaluate whether it was realistic for the client to lose 4.5 kg in three months re-flects an action to be taken after the interview to further determine how the care plan will be modified.