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.
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Related Questions
Correct Answer is B
Explanation
A. Using authoritative leadership to help clients learn to conform to societal norms: Authoritative leadership may be perceived as controlling and is unlikely to be effective with clients diagnosed with borderline personality disorder. It can lead to resistance and difficulties in building a therapeutic alliance.
B. Being firm, consistent, and empathetic, while addressing specific client behaviors: This approach is most appropriate. Clients with borderline personality disorder often benefit from clear and consistent boundaries, along with empathy from the nurse. Addressing specific behaviors helps establish a structured and safe therapeutic environment.
C. Promoting client expression by implementing laissez-faire leadership: Laissez-faire leadership, characterized by minimal interference or direction, is generally not suitable for clients with borderline personality disorder. They may struggle with emotional dysregulation and benefit from a more structured and supportive approach.
D. Overlooking inappropriate behaviors to avoid promoting secondary gains: Overlooking inappropriate behaviors may reinforce maladaptive patterns and hinder progress in therapy. It is essential to address and work through specific behaviors while maintaining empathy and consistency.
Correct Answer is D
Explanation
A. Case Manager:
A case manager is typically responsible for coordinating and managing the overall care and services for a client. This role involves collaboration with various healthcare professionals and services outside the immediate treatment setting.
B. Educator:
An educator is involved in providing information, teaching, and promoting the understanding of health-related topics. While education is an essential component of nursing care, the described actions are more indicative of another role.
C. Counselor:
A counselor focuses on providing emotional support, guidance, and therapeutic communication to help clients explore and address personal issues. While nurses do engage in counseling, the described actions emphasize a broader role.
D. Milieu Manager:
The role of a milieu manager involves organizing and maintaining the therapeutic environment, including scheduling activities, managing interactions, and ensuring safety on a psychiatric unit. This role is crucial for creating a supportive and therapeutic atmosphere for clients.
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