A Nurse Identifies a Fall Risk When Assessing a Patient

question 19

Multiple Choice

A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient?

• A) Identify factors interfering with goal achievement.
• B) Counsel the nursing assistive personnel on duty when the patient fell.
• C) Remove the fall risk sign from the patient's door because the patient has suffered a fall.
• D) Request that the more experienced charge nurse complete the documentation about the fall.

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Definitions:

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