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    Ati nur 3150 med surg Proctored exam (CC1) ICHS college

    As a patient is ambulating to the bathroom, they fall. Which initial action will the nurse take next to ensure the care plan is accurately revised?

    Explanation & Rationale

    A. Assessment is the first and most critical step of the nursing process following any adverse event like a fall. The nurse must collect data on the patient's physical and neurological status to identify any immediate injuries or changes in condition. This objective and subjective information is the prerequisite for making any meaningful revisions to the patient's care plan. B. Establishing a new plan of care cannot occur until a comprehensive assessment has been performed to determine why the fall occurred and what new needs exist. Jumping directly to planning without data collection leads to ineffective or inappropriate interventions. The assessment findings will dictate the specific modifications required to ensure the patient's future safety and recovery. C. Consulting physical therapy may be a necessary later step to address gait or balance issues, but it is not the initial action for revising the nursing care plan. The nurse must first evaluate the patient's immediate safety and clinical status following the incident. Physical therapy serves as a collaborative intervention that is informed by the nurse's initial post-fall assessment. D. While priorities will likely change after a fall, the nurse must first assess the patient to understand what those new priorities should be. For example, the priority might shift to pain management or neurological monitoring based on the assessment findings. Setting priorities is a component of the planning phase, which must always be preceded by the assessment phase.

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