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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Client diagnosed with hypomania who is speaking loudly on the unit: While hypomanic individuals may exhibit increased energy and talkativeness, the urgency is lower compared to a client expressing active suicidal ideations. This client does not pose an immediate threat to themselves or others.
B. Client diagnosed with mania who expressed active suicidal ideations: This is the correct answer. A client with active suicidal ideations is at an elevated risk and requires immediate attention. Suicidal thoughts in the context of mania can be impulsive, and prompt intervention is crucial to ensure the client's safety.
C. Client with a history of mania who is pacing in the hallway: Pacing may be a symptom of mania, but without additional information about the client's current state and any potential immediate risks, the client expressing active suicidal ideations takes precedence.
D. Client diagnosed with hypomania who is complaining of pain: Pain complaints, in the absence of other urgent factors, do not take precedence over active suicidal ideations. The risk of harm to oneself or others is a higher priority.
Correct Answer is D
Explanation
A. Histrionic Personality Disorder:
Individuals with histrionic personality disorder typically seek attention and may be overly dramatic, but self-harm as a response to perceived abandonment is not a characteristic feature.
B. Obsessive-Compulsive Personality Disorder (OCPD):
People with obsessive-compulsive personality disorder are characterized by perfectionism, preoccupation with details, and a desire for control. Michelle's behavior, including self-harm in response to perceived rejection, aligns more closely with borderline personality disorder.
C. Narcissistic Personality Disorder:
While narcissistic individuals may exhibit a sense of superiority and a desire for admiration, self-harm in response to abandonment is not a typical trait of narcissistic personality disorder.
D. Borderline Personality Disorder (BPD):
This personality disorder is characterized by unstable relationships, self-image, and emotions. Individuals with BPD may have intense fears of abandonment and engage in impulsive and self-destructive behaviors. Michelle's perception of being disliked, her claim of superiority, and the self-harming action in response to news of the nurse's vacation are consistent with BPD.
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