HELP, an RN exam review question

[coldviva204]

Jane, 18 years old, is brought to the hospital by her mother after she intentionally slashed her left wrist. Jane's mother tells the nurse that prior to this incident her daughter had been distraught over a breakup with her boyfriend.

As the nurse is assessing Jane's wounds, Jane expresses a desire to kill herself. She is to be admitted to the psychiatric unit for observation. What is the appropriate sequence of nursing actions?

1)Dress the wounds, ensure that Jane cannot harm herself and prepare her for admission.

2)Ensure that Jane cannot harm herself, prepare her for admission and dress the wounds.

3)Ensure that Jane cannot harm herself, dress the wounds and prepare her for admission.

4)Dress the wounds, prepare Jane for admission and ensure that she cannot harm herself.

What do you Guys think the answer is? I got this question wrong and I want to know what you think the answer is and how you arrived at the answer. I will post the answer tomorrow

THanks :)

[Jolie, BSN]

Based upon Maslow's Hierarchy, what would your answer be?

[MPKH, BSN, RN]

I think the first choice is the correct answer.

This question is a prioritization question. Out of the three options given--dressing the wound, ensuring patient safety, and admission prep work--which one ought to be done first, second and third? Going by Maslow's hierarchy of needs, addressing the patient's physiological needs trumps safety. Therefore, performing the wound dressing addresses the physiological need of the patient (helping her to restore a state of hemostasis). Next, the safety of the patient must be addressed--as the patient admits to having suicidal thoughts, the nurse must react appropriately, and to ensure that the patient can not harm herself (or anybody else). An assessment of the patient's suicidal tendency ought to be carried out. Lastly, as admission prep work isn't all that urgent, it can be done last.

Hope that helps.

[ashleyisawesome, BSN, RN]

i agree with mpkh, i think its the first for the same reasons. if its not 1, i would go with 3.. but if you are dressing her wound, you are right there with her to ensure she cant harm herself anyway.

[Double-Helix, BSN, RN]

I would choose 3. It doesn't appear that the bleeding is life threatening or she would be admitted to a medical unit, not a psychiatric unit.

When a patient expressed a desire to harm themselves, that is the most important thing to address. If you ever get a question "What patient should you see first" and one of them is suicidal- that is the one you see first.

If you choose to dress the wounds first, Jane could grab something sharp in the room and hurt herself. So the first thing you do is make sure she is safe. Once she is not able to harm herself, take care of the medical need- the wounds. Then prepare her for admission (paperwork, explanations, etc.).

[FORTHELOVEOF!!!!]

When I read it I picked 3, but I do see MPKH's point as well, what was the answer?

[Esme12, ASN, BSN, RN]

which is causing the most risk to the patients life

look at maslow's to tell you which priority precedes the next. don't forget erickson growth and development

as the nurse is assessing jane’s wounds, jane expresses a desire to kill herself. she is to be admitted to the psychiatric unit for observation. what is the appropriate sequence of nursing actions?

the answer is in the question.... to be admitted to the psych unit and she is talking it has been determined that she doesn't require medical admission. her safety is paramount as evidenced by her present attempt to harm herself, dress the wounds and get her to a secure environment.

what was the answer?

[coldviva204]

The answer is 3 :)

I thought it was 1 at first. But I forgot to consider that if Jane is in seriously medical attention, she would be in the medical unit not the psych unit.

Thanks Ashley and Esme for sharing your critical thinking process.

[morte, LPN, LVN]

weelll, I knew it was 2 or 3....I went for 2 because it seemed the wrist wound had to be very minor, and fact she was being admitted to a psych floor was probably going to be traumatic, i figured some prep work in that regard would be good.

[OB-nurse2013, BSN, RN]

My answer would be 3 :)

[KatePasa]

3. It's a safety question. She's states she wants to kill herself. So if your bandage scissors are within reach or there is a roll of gauze nearby...she might try. You should also assess that she's not bleeding profusely (safety). Ensure safety, then proceed with task at hand. Assessment is always first. Ensuring safety is an assessment action,

[KatePasa]

I also want to add that sometimes people follow Maslow's to a fault. What I do is get myself into the scenario by imagining myself or a nurse I respect performing the actions. Or I imagine verbalizing it in my head..."Jane, I want to make sure you're safe, then I am going to dress your wounds now and then we'll prepare you for admission" sounds more therapeutic than "Jane, I am dressing your wound. Then, I'll make sure you're safe and we'll prepare you for admission".

In my experience, a little imagination goes a LONG way in answering nursing exam questions!