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 C

Explanation

A. Favoring clients over others based upon their mental health diagnosis is not an indication of bias: This statement is incorrect. Favoring or discriminating against clients based on their mental health diagnosis is a clear indication of bias, and it is an issue that the nursing profession aims to address.

B. Displaying basis & conscious art: It seems like there might be a typo in this option. Assuming it means "Displaying bias, conscious or not," this could be a relevant point in discussing unconscious biases that individuals may hold, impacting their interactions with clients.

C. There is a negative stigmatization for mental lives: This is the correct answer. This statement acknowledges the existence of negative stigmatization associated with mental health. Addressing and reducing mental health stigma is an essential aspect of providing quality mental health care.

D. Bias is often isolated to inpatient hospitalization: This statement is not accurate. Bias can manifest in various healthcare settings, not just inpatient hospitalization. It is important to address bias across all levels of care to ensure equitable and unbiased treatment for individuals with mental health concerns.

A. less-restrictive alternatives have been tried without success B. the medication will make the work of the staff easier or safer C. the client is willing to accept the medication D. the clients behavior indicates possible danger to self, others or the environment

Correct Answer is D

Explanation

A. Less-restrictive alternatives have been tried without success: While it is important to explore less-restrictive alternatives before resorting to medication, the immediate concern is the client's safety and the safety of others. If the client's behavior poses a significant risk, prompt intervention may be necessary.

B. The medication will make the work of the staff easier or safer: While staff safety is important, the primary consideration for administering a prn dose of Haloperidol is the clinical need based on the client's behavior and potential danger to themselves, others, or the environment.

C. The client is willing to accept the medication: Client willingness to accept medication is relevant for promoting collaboration in treatment, but the urgency in administering a prn dose is often based on the client's behavior and the level of risk they pose.

D. The client's behavior indicates possible danger to self, others, or the environment: This is the most critical factor in determining the need for a prn dose. If a client's behavior poses a significant risk, such as aggression, violence, or extreme agitation, administering a prn dose of medication may be necessary to ensure safety and prevent harm.

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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 nurse is discussing bias issues in mental health with a newly licensed nurse. Which of the following statements should the nurse include in the discussion?

Correct Answer is C

Explanation

For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

Correct Answer is D

Explanation

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