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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. fluoxetine (Prozac):
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. While SSRIs can have side effects, significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance are not typically associated with fluoxetine. The primary concerns with SSRIs are related to serotonin levels and can include gastrointestinal disturbances, insomnia, and sexual dysfunction.
B. Lithium (Lithobid):
This is the correct answer. Lithium is known to have potential side effects related to cardiac and cerebral function, as well as fluid and electrolyte balance. Monitoring blood levels of lithium is crucial to avoid toxicity, which can affect the cardiovascular and central nervous systems. Lithium toxicity can lead to symptoms such as tremors, confusion, ataxia, and, in severe cases, seizures.
C. venlafaxine (Effexor):
Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) commonly used to treat depression and anxiety disorders. While it can cause some cardiovascular effects, the concern for significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance is generally lower compared to lithium. The primary side effects of venlafaxine are related to serotonin and norepinephrine levels and may include increased blood pressure and heart rate.
D. clozapine (Clozaril):
Clozapine is an atypical antipsychotic medication used to treat schizophrenia. While antipsychotics can have side effects related to metabolic changes, significant alterations in cardiac or electrolyte imbalances are not typically associated with clozapine as the primary concern. Regular monitoring for metabolic side effects, such as weight gain and changes in lipid and glucose levels, is important with antipsychotic medications.
Correct Answer is C
Explanation
A. Incorrect. Mental health and mental illness are not the same concepts. Mental health refers to a person's emotional, psychological, and social well-being, while mental illness refers to specific mental health conditions that significantly affect a person's thoughts, emotions, and behaviors.
B. Incorrect. Mental health and mental illness can both present at any age. Mental health is a broader concept that encompasses overall well-being, while mental illnesses can manifest at various stages of life.
C. Correct. This statement accurately distinguishes between mental health and mental illness. Mental health involves the ability to cope with daily stressors, while mental illness is characterized by disruptions in activities of daily living due to specific mental health conditions.
D. Incorrect. This statement confuses the relationship between mental health and mental illness. Mental health is a broader concept that contributes to overall well-being, while mental illness is a specific condition that may arise due to various factors, including poor mental health.
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