Difficulty: Medium
Average Score: 80%
Simulated
A client is being admitted to the psychiatric unit for depression and self mutilation. Which intervention should the nurse implement first?
Correct answer
C
Rationale
The priority is immediate client safety. Given the admission is for self-mutilation, the nurse's first action must be to assess the current, acute risk of self-harm to determine if immediate safety precautions are needed. While a full assessment (A) and building a relationship (B) are crucial subsequent steps, they are secondary to evaluating imminent danger. Obtaining a history from a significant other (D) delays the direct assessment of the client's present state and risk.