On nursing rounds, a client is found lying on the floor. Which statement would be most appropriate for the nurse aide to record in the client's medical record?
A)"It is most likely that the client attempted to climb over the side rails and fell."
B)"Upon entering the room, the client was found lying on the floor."
C)"The client had been restless all evening and was trying to get out of bed."
D)"The presence of a bed alarm could have prevented the fall."

Question

Quizplus · Accepted Answer

The nurse aide should document only the facts of the situation. Based on the scenario, the cause of the fall was not identified. Thus the facts for documentation are that the client was found lying on the floor upon entering the room.

On Nursing Rounds, a Client Is Found Lying on the Floor