A female client who received a sedativehypnotic medication at bedtime becomes confused during the night. The client gets out of bed and falls, sustaining a laceration that requires suturing. Which statement would be included as part of the nurse’s documentation in the client’s chart?
a. “Client fell due to confusion caused by sleeping medication.”
b. “Client found lying on the floor in a pool of blood. Nursing assistant forgot to put siderails up at bedtime.”
c. “Client found sitting in the floor. 3cm laceration above left eyebrow. Oriented to name only.”
d. “Client slipped in water on floor cause by leaking faucet that was reported to the maintenance department two days ago.”
Answer C. This statement presents some of the facts and assessments related to this event. The nurse would also include vital signs further assessment, notification of physician, treatment or procedures done per physician orders, and client’s response.
a. “Client fell due to confusion caused by sleeping medication.”
b. “Client found lying on the floor in a pool of blood. Nursing assistant forgot to put siderails up at bedtime.”
c. “Client found sitting in the floor. 3cm laceration above left eyebrow. Oriented to name only.”
d. “Client slipped in water on floor cause by leaking faucet that was reported to the maintenance department two days ago.”
Answer C. This statement presents some of the facts and assessments related to this event. The nurse would also include vital signs further assessment, notification of physician, treatment or procedures done per physician orders, and client’s response.