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. A Client diagnosed with hypomania who is speaking loudly on the unit B. A client diagnosed with mania who expressed active suicidal ideations C. A client with a history of mania who is pacing in the hallway D. A client diagnosed with hypomania who is complaining of pain

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.

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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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