On Nursing Rounds, a Client Is Found Lying on the Floor

Multiple Choice

On nursing rounds, a client is found lying on the floor. Which statement would be most appropriate for the nurse aide to record in the client's medical record?

A) "It is most likely that the client attempted to climb over the side rails and fell."
B) "Upon entering the room, the client was found lying on the floor."
C) "The client had been restless all evening and was trying to get out of bed."
D) "The presence of a bed alarm could have prevented the fall."