Question

A client climbs over the side rails and falls after the nurse has instructed the client to remain in bed. What information should the nurse leave out of the medical chart?

a) Names of witnesses
b) That the nurse was called to another unit to assist with a procedure
c) That the client received a sedative one hour prior to the incident
d) That the client disregarded the nurse's instructions on not getting out of bed

Answer 1

The nurse should leave out certain details from the medical chart while documenting a client's fall incident, including the nurse being called to another unit and the client receiving a sedative, but important details like the client disregarding instructions should be included.

Step-by-step explanation:

Subject: Medicine

Grade: College

The nurse should leave out b) That the nurse was called to another unit to assist with a procedure and c) That the client received a sedative one hour prior to the incident from the medical chart.

Leaving out the names of witnesses can compromise the client's privacy and could also hinder any potential legal actions that may arise. However, it is important to document any witness accounts of the incident privately for reference.

Item d) That the client disregarded the nurse's instructions on not getting out of bed should be included in the medical chart as it provides relevant information about the client's actions leading to the fall.