Samuel, a 19-year-old high school student, has been admitted to the psychiatric unit with a diagnosis of adjustment disorder with disturbance of conduct. He assaulted a teacher when he was told he was receiving detentions for a pattern of tardiness
The nurse, while completing rounds, finds the patient in his room crying, and one of his wrists is bleeding from a self-inflicted cut made by a piece of metal from an unknown source. Prioritize each of the following nursing interventions from 1 to 5, with 1 being the highest priority.
___ A. Check the patient's vital signs.
___ B. Assess the wound site.
___ C. Contact the parents.
___ D. Discuss with Samuel what precipitated this event.
___ E. Cleanse and treat the wound site to prevent infection.
ANS:
A: 3
B: 1
C: 5
D: 4
E: 2
The first priority is assessment (Item B), followed by providing care to meet physical and safety needs (Items E and A). The next priority is responding to the patient's emotional needs (Item D), and finally, contacting the patient's parents (Item C) in accordance with standards for confidentiality of medical information.
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