Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5035

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5035

QUESTION: A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially?

✘O a.) Enter the room quietly and move beside her to assess her injuries.
✘O b.) Call for staff back-up before entering the room and restraining her.
✘O c.) Move as much glass away from her as possible and sit next to her quietly.
✓O d.) Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.

RATIONALE

RATIONALE: Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. After explaining that the nurse is there to help, the nurse should observe the client's response carefully. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the client or examine injuries without first announcing the nurse's presence and assessing the dangers of the situation.
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge