The client is a 19-year-old high school student who has been admitted to the psychiatric unit with a diagnosis of adjustment disorder with disturbance of conduct. The client assaulted a teacher after being informed of imminent detentions for a pattern of tardiness. The nurse, while completing rounds, finds the client in their room crying, and one of their 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.
___ 1. Obtain the client's vital signs.
___ 2. Assess the wound site.
___ 3. Contact the health-care provider.
___ 4. Discuss with the client what precipitated this event.
___ 5. Cleanse and treat the wound site to prevent infection.

Question

Quizplus · Accepted Answer

2.Assess the wound site. Assessment is the first step of the nursing process. Check the wound first to ensure circulation is adequate.
1.Obtain the client's vital signs. Obtain the physical assessment data.
5.Cleanse and treat the wound. This nursing implementation addresses the physical need first. Physical needs should be addressed before emotional needs
3.Contact the health-care provider. The health-care provider will need to further evaluate the client.
4.Discuss what precipitated this event. This implementation addresses the emotional needs and provides additional assessment (subjective data). This would occur after the client's safety was ensured.

The Client Is a 19-Year-Old High School Student Who Has