The nurse enters a patient's room and finds her in the bathroom with lacerations to the wrists. The patient is surrounded by broken glass and blood and appears calm. What should the nurse do next?


•The safety of the nurse and patient is the first priority. The patient cannot be safety assessed in this situation. Remaining calm, the nurse should call for help and then request that the patient leave the area to move to a treatment room to be assessed. If she does not agree, another staff person can provide assistance by removing the broken glass, but only after the first nurse confirms that the patient is not a threat to the staff.

Incorrect options:

•Restraining the patient before assessing her is not appropriate.

•Going to the patient's side to assess her is unwise. The patient may be frightened or defensive, and may have broken glass in her hand that could be used as a weapon.

•Moving the glass should be done only after the nurse confirms that the environment is safe.

Visit our website for other NCLEX topics now!