A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patients vital signs are within reference ranges
And the nurse observes no apparent injuries. What is the nurses most appropriate action?

Question

Quizplus · Accepted Answer

A fall would necessitate thorough medical assessment due to the patients risk of bleeding. The nurses abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.

A Nurse Has Entered the Room of a Patient with Cirrhosis