A nurse is researching data about best practice for reducing medication errors on a surgical unit. Which of the following steps of evidence based practice (EBP) is the nurse taking?

Explanation:

A. Administer the Hamilton depression scale:

The Hamilton Depression Rating Scale is a tool used to assess the severity of depression symptoms in individuals. While assessing the client's depression level is an important aspect of mental health assessment, it is not the immediate priority in this scenario. The client has been admitted following a suicide attempt, indicating an acute risk to their safety. Therefore, the priority at this stage is to ensure the client's safety and prevent any further harm or attempts at self-harm.

B. Make a contract with the client for weight gain:

Making a contract with the client for weight gain, especially in the context of anorexia nervosa, may be an important aspect of the client's overall treatment plan. However, in this scenario, the client's immediate safety takes precedence. The client has a history of depression, substance abuse, and anorexia nervosa, and the primary concern at admission is to prevent any further self-harm or suicide attempts.

C. Review the client's toxicology laboratory report:

Reviewing the client's toxicology laboratory report is important for understanding any recent substance abuse and its potential impact on the client's physical and mental health. However, while this information is relevant to the client's overall care, it is not the first action to take upon admission. The immediate priority is to ensure the client's safety and provide appropriate monitoring and intervention to prevent further harm.

D. Initiate one-to-one nursing observation:

This is the correct answer. Initiating one-to-one nursing observation means assigning a dedicated nurse to continuously monitor and supervise the client closely. This level of observation is crucial in a situation where there is a history of suicide attempt and ongoing risk of self-harm. One-to-one observation allows for immediate intervention if the client shows signs of distress or attempts to harm themselves, ensuring their safety while they are in the acute mental health unit.

Explanation:

A. Arrange referral for family therapy to deal with home stressors:

While family therapy may be beneficial for addressing home stressors, it is not the first step when there is a suspicion of physical abuse. The priority in cases of suspected abuse is to ensure the client's safety and to report the suspicion to the appropriate authorities.

B. Follow the agency's guidelines for reporting suspected abuse:

This is the correct action to take first. Nurses are mandated reporters, and they must follow their agency's protocols and legal requirements for reporting suspected abuse. Reporting ensures that the client's situation is investigated promptly, and appropriate interventions are implemented to protect the client.

C. Check the bruises at the next visit to the client's home:

Delaying action and waiting until the next visit to check the bruises is not appropriate in cases of suspected abuse. Immediate action is necessary to address the safety of the client. Suspected abuse should be reported promptly to the relevant authorities for investigation.

D. Institute more frequent visits to the client's home:

Increasing the frequency of visits may not address the immediate safety concerns of the client if abuse is suspected. While increased monitoring may be necessary in certain situations, reporting the suspicion of abuse and initiating appropriate interventions should take precedence.