NCLEX PN Exam Practice Test Practice Question
Scenario/Extract:
1700
Found client lying on floor next to bed. Client states, "I fell out of bed while reaching for my eyeglasses and hit my head on the bedside table." Client is alert and oriented to time, place, person, and situation. Denies pain, dizziness, or nausea. No visible injuries. Assisted back to bed. Neurological vital signs within normal limits (see assessment flow sheet). Client instructed to use call bell for assistance. Will continue to monitor. __________RN
1710: Health care provider (HCP) notified of fall. Prescribed CT of head STAT. ___________RN
1740: No change in neurologic status. Client to CT via gurney. Report filed per policy. __________RN
1810: Client returned from CT. No change in neurologic status. Reinforced use of call bell, and client demonstrated understanding. Will continue to monitor. __________RN
The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time?
Correct Answer: C
Rationale: Without specific exhibit details, 1740 is assumed incorrect based on context, possibly due to a documentation error related to the fall. Rationale is limited without exhibit.
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