Question

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.

Answer 1

a. Identify factors interfering with goal achievement. The nurse's priority when evaluating the patient after a fall is to identify factors interfering with goal achievement.

Step-by-step explanation:

The nurse's priority when evaluating the patient after a fall is to identify factors interfering with goal achievement. This means that the nurse should assess and determine what caused the fall and what can be done to prevent future falls. It is important to uncover any underlying issues such as environmental hazards, medication side effects, or mobility limitations that may have contributed to the fall. By addressing these factors, the nurse can develop a comprehensive fall prevention plan to keep the patient safe.

In this scenario, it is not the priority for the nurse to counsel the nursing assistive personnel on duty or remove the fall risk sign from the patient's door. While these actions may be necessary, they should be addressed after identifying the factors contributing to the fall. Requesting the more experienced charge nurse to complete the documentation about the fall is also not the priority at this moment.