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 A

Explanation

A. Correct. Using the proportion, the correct dose of fluoxetine (Prozac) for the prescribed 60 mg is 15 mL.

B. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 20 mL.

C. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 25 mL.

D. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 10 mL.

A. I'm the world's most perceptive attorney. B. The FBI is out to get me C. I can't stop my sexual urges. They have led me to numerous affairs. D. My wife is distraught about my overspending

Correct Answer is A

Explanation

A. "I'm the world's most perceptive attorney.": This statement reflects grandiosity, a common feature of grandiose delusions. The client is expressing an exaggerated belief in their own importance and abilities, indicating a distorted perception of reality.

B. "The FBI is out to get me": This statement suggests paranoid delusions, where the client believes they are being persecuted or conspired against. It does not specifically indicate grandiose delusions.

C. "I can't stop my sexual urges. They have led me to numerous affairs": This statement reflects impulsivity and hypersexuality, which are common features in manic episodes but do not specifically indicate grandiose delusions.

D. "My wife is distraught about my overspending": This statement reflects a consequence of manic behavior (overspending) but does not directly indicate grandiose delusions.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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