Question

One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client?

A."Incident report completed."
B.The reason the client was unattended
C.The vital signs and assessment of the client
D.Location of the incident report

Answer 1

The most vital information to record in the nursing notes after a client falls is the vital signs and assessment of the client, which includes observations on the client's immediate physical and emotional state.

Step-by-step explanation:

When filling out the nursing notes after an incident where a client falls, it is critical to include detailed information that reflects the client's condition and the circumstances surrounding the incident. Among the options provided, the most vital details to document would be C. The vital signs and assessment of the client. This should include any observations made about the client's condition, such as levels of consciousness, pain, possible injuries, and overall physical and emotional state immediately following the incident. Moreover, recording the reason the client was unattended may be important for internal review and to prevent future incidents, but it does not directly relate to the client's health status at the time of the incident. Lastly, while the incident report's location may be useful internally, it is not necessary in the nursing notes regarding the client's immediate care and condition.