Author Question: A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient ... (Read 32 times)

bio_gurl · **on:** Jul 22, 2018

A nurse identifies a fall risk 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.

Which action is the nurse's priority when evaluating the patient?
a. Identify factors interfering with goal achievement.
b. Counsel the nursing assistive personnel on duty when the patient fell.
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

A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?

a. I'm worried about what those other girls will think of me.
b. I can't wear that color. It makes my hips stick out.
c. I'll wear the blue dress. It matches my eyes.
d. I will go to the pool next summer.

eliasc0401 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: A
When goals and outcomes are not met, you identify the factors that interfere with their achievement. 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 assistive personnel; 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: C
The nurse is evaluating the improvement in body image. The only positive comment made is that the patient is wearing the blue dress to match her eyes. Worrying about others, making my hips stick out, and going to the pool next summer do not reflect positive changes in body image.