A client is admitted with symptoms of psychosis. The nurse hurries to the client's room when she hears the client calling for help. She finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which of the following statements should the nurse document in the incident report?

Question

Quizplus · Accepted Answer

The nurse should document that the client was found lying on the floor, as this is the objective fact that occurred. While the client's behavior (trying to lower side rails or get out of bed) may be relevant information, it is not the direct observation that occurred and should not be stated as fact in the incident report. Noting that the client was unaware they had fallen is also subjective and not a direct observation, so it should not be included in the incident report.

A Client Is Admitted with Symptoms of Psychosis