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. Disturbed sensory perception: While the client is experiencing disturbed sensory perception (auditory hallucinations), the priority is to address the potential harm to others, which is better captured by the "Risk for violence: directed toward others" diagnosis.

B. Risk for violence: directed toward others: This diagnosis is the priority in this situation because the client is expressing homicidal thoughts directed toward a specific target (the president). Ensuring the safety of the client and others is the primary concern.

C. Altered thought processes: Altered thought processes may be evident in psychotic disorders, but the immediate concern is the risk of violence. Addressing altered thought processes would be part of the overall care plan, but it may not be the immediate priority in this case.

D. Risk for injury: While the client may be at risk for injury, the specific concern mentioned by the client is the potential harm to others (the president). Therefore, the "Risk for violence: directed toward others" diagnosis takes precedence.

A. Psychiatrist B. Behavioral therapist C. Social worker D. Psychologist

Correct Answer is C

Explanation

A. Psychiatrist: Psychiatrists focus primarily on medical and pharmacological interventions for mental illnesses. While they play a crucial role in diagnosing and treating mental health conditions, they typically do not have the expertise in housing assistance or social services.

B. Behavioral therapist: Behavioral therapists focus on psychotherapeutic interventions to address and modify behavior. They are not typically involved in addressing social determinants of health, such as housing.

C. Social worker: Social workers are specifically trained to address social issues, including housing. They work with clients to assess their social needs, connect them with resources, and advocate for their well-being. In this case, a social worker would be instrumental in helping the client find housing resources and support.

D. Psychologist: Psychologists primarily focus on psychological assessments, therapy, and interventions. Like psychiatrists, their expertise is more centered around mental health treatment rather than addressing the social determinants of health such as housing.

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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

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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