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. "I will take Lithobid on an empty stomach": This statement is incorrect. Lithobid is usually taken with meals or right after meals to minimize gastrointestinal side effects. Taking it on an empty stomach may lead to increased side effects.

B. "I will maintain normal salt intake": This statement is correct. Lithium levels in the blood can be influenced by sodium levels. Maintaining a consistent and normal salt intake is important for the proper functioning of lithium in the body. Both low and high sodium levels can affect lithium levels.

C. "I will consume more fluids": This statement is generally correct. Adequate fluid intake is important to prevent dehydration, as lithium is excreted by the kidneys. However, it should be balanced, and excessive fluid intake should be avoided to prevent lithium toxicity.

D. "I will limit my intake of fluids daily": This statement is incorrect. While fluid intake should be monitored and maintained at a reasonable level, restricting fluids too much can lead to dehydration and an increased risk of lithium toxicity.

A. Maintain consistency of care by open communication to avoid staff manipulation B. Maintain unit order by the application of autocratic leadership C. Allow the clients to apply the democratic process when developing unit rules D. Allow the client spokesperson to verbalize concerns during a unit staff meeting

Correct Answer is A

Explanation

A. Maintain consistency of care by open communication to avoid staff manipulation: This is the correct answer. Borderline personality disorder (BPD) clients may engage in splitting behaviors, which involve polarized views of staff as either all good or all bad. Maintaining consistency of care and open communication can help prevent manipulation and ensure fair and transparent interactions.

B. Maintain unit order by the application of autocratic leadership: Autocratic leadership, characterized by a top-down approach with limited input from others, may not be the most effective strategy in this situation. It may lead to resistance from clients and potentially escalate the conflict.

C. Allow the clients to apply the democratic process when developing unit rules: While democratic processes are generally beneficial, allowing clients to unreasonably demand modifications of unit rules without considering the overall impact on the therapeutic environment may not be appropriate. It's important to balance client involvement with maintaining a structured and therapeutic milieu.

D. Allow the client spokesperson to verbalize concerns during a unit staff meeting: While it's important to provide a platform for clients to express concerns, allowing a spokesperson to verbalize concerns during a staff meeting should be done in a manner that maintains order and follows the therapeutic goals of the unit. It should not involve unreasonably demanding modifications without a careful consideration of the impact on the overall treatment milieu.

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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

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?

Correct Answer is B

Explanation

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation?

Correct Answer is A

Explanation

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