A Client Is Admitted with Symptoms of Psychosis

Multiple Choice

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room when she hears the client calling for help. She finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which of the following statements should the nurse document in the incident report?

A) The client was trying to lower the side rails.
B) The client was found lying on the floor.
C) The client was trying to get out of the bed.
D) The client was not aware that he had fallen.