A nurse identifies a nursing diagnosis of Risk for falls 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.What is the nurse's priority action when evaluating the patient's plan of care?

A) Counsel the unregulated care provider on duty when the patient fell.
B) Identify factors interfering with goal achievement.
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.

Question

Netsanet Belachew · Accepted Answer

Final Answer : B, Explanation :  After a change in the patient's condition or an untoward event,the nurse attempts to identify factors interfering with goal achievement.In this case,the nurse identifies the factors that interfered with goal achievement to determine the cause of the fall.The fall may not have been due to an error by the unregulated care provider;therefore,counselling should be reserved until after the cause has been determined.The patient remains at risk for falls,so the fall risk sign should remain on the door.The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation.The charge nurse can be consulted to review the documentation.

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