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
My choice was 3 as well. I see everyones point about physiological needs first following Maslow, but if you look up Maslow's hierarchy, the description of physiological needs includes air, water, food, etc, not wound dressings. Also, take into account that they obviously aren't too worried about the wound if they're sending her to psych, not medicine. If her would was gushing and she was pale with a low BP, that would be a different story.
I would answer 3 - harm always needs to be addressed first. You don't want her grabbing a razor out of her pocket or a pair of scissors from the table and trying to hurt herself more while you are dressing the wounds. From what I've heard from psych nurses, patients can get very creative with objects you'd never think they could harm themselves with. Obviously you want to address immediate safety issues - self-harm and open wounds before you start the admission process.
LadyinScrubs, ASN, RN
788 Posts
I vote for #3. There is a suicide attempt; safety first, always. IMO dress wounds and admit follows.