A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

Implement the client's behavioral modification plan

Document the size and location of the cuts

Administer a tetanus antitoxin.

inspect the cuts for debris

Answer and Explanation

The Correct Answer is D

A. Implement the client's behavioral modification plan:

While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.

B. Document the size and location of the cuts:

Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.

C. Administer a tetanus antitoxin:

Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.

D. Inspect the cuts for debris:

This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.

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Correct Answer is B

Explanation

A. "Group therapy is an economical way of providing therapy to many clients concurrently.": While this statement may be true, it does not directly address the client's concerns or provide information about the voluntary nature of group participation.

B. "Group therapy is optional. You can go if you find the topic helpful and interesting.": This is the correct answer. Acknowledging the client's autonomy and providing information about the voluntary aspect of group therapy respects the client's preferences and promotes a collaborative therapeutic relationship.

C. "Group therapy is mandatory. All clients must attend.": This statement is more authoritarian and does not take into account the individual needs and preferences of the client. It is important to involve clients in decisions about their treatment whenever possible.

D. "The purpose of group therapy is to learn and practice new coping skills.": While this statement provides information about the purpose of group therapy, it does not directly address the client's question about the optional nature of attendance.

A. By using a screening tool such as the CAGE questionnaire B. By asking directly if the client has ever had a problem with alcohol C. By holistically assessing the client using the CINA scale D. By referring the client for physician evaluation

Correct Answer is A

Explanation

A. By using a screening tool such as the CAGE questionnaire: This is the correct answer. The CAGE questionnaire is a widely used tool for screening alcohol use disorders. It consists of four questions that assess whether the individual has concerns or issues related to their alcohol consumption. A positive result may indicate a need for further assessment and intervention.

B. By asking directly if the client has ever had a problem with alcohol: While direct questioning is important, using a structured screening tool provides a more standardized and objective approach. The CAGE questionnaire offers specific questions that help identify potential issues with alcohol use.

C. By holistically assessing the client using the CINA scale: The CINA scale (Checklist of Nonverbal Indicators of Affect) is primarily used to assess nonverbal behaviors related to affect. While it may be useful in certain contexts, it is not specifically designed for assessing alcohol use disorders.

D. By referring the client for physician evaluation: While physician evaluation may be necessary for a comprehensive assessment, using a screening tool such as the CAGE questionnaire is an appropriate initial step. The results of the screening tool can guide further assessment and appropriate referrals.

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A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

Nursing Test Bank

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