A practical nurse (PN) at a community mental health day program is greeting a 25-year-old client with an intellectual disability. The PN observes fresh, bilateral, rope-like abrasions on the client's wrists. In what order should the PN perform the following actions? (Arrange the actions from first to last.)
- 1Escort the client to a private area away from other individuals.
- 2Inquire about the injuries using non-leading, open-ended questions.
- 3Perform a focused physical inspection to evaluate the extent of the abrasions.
- 4Notify the supervising registered nurse (RN) about the findings.
- 5Document the objective observations and the client's exact statements in the health record.
Cevap
The correct sequence prioritizes client safety first, followed by data collection (subjective then objective), reporting to the supervisor, and finally documentation.
According to the nursing process and prioritization frameworks, client safety is the paramount concern. Therefore, the first action is to separate the client to establish a safe, private environment. Next, the nurse collects data, beginning with non-leading subjective inquiries followed by a focused objective physical inspection. Once sufficient data is gathered to suspect abuse, the PN must promptly communicate these findings to the supervising RN to trigger mandatory reporting procedures. Finally, the nurse meticulously documents the objective physical findings and the client's exact statements in the medical record.
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Anahtar Kavram
Prioritization in Suspected Abuse