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A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?1 A statement that the nursing staff was not at fault because the client initiated the accident.2 A listing of facts related to the incident as witnessed by the nurse.3 The name of the nurse who was responsible for implementing the restraints.4 The potential reasons why the restraints were not in place at the time of the fall.
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