When Responding to a Call Light,the Nurse Finds a Client

Multiple Choice

When responding to a call light,the nurse finds a client lying on the floor,with the bed linens around the legs.Which chart entry should the nurse document for this finding?

A) Client fell out of bed,but did push the call button for assistance.
B) Client became tangled in the bed linens,then called for assistance after falling out of bed.
C) Recorder responded to client's call light,upon entering the room,found client on floor.
D) Client found on floor,appeared to have fallen out of bed as a result of getting tangled in bed linens.