Difficulty: Medium
Average Score: 71%
Simulated
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?
Correct answer
B
Rationale
The correct answer is B: Inspect the cuts for debris. The nurse should first assess the client's physical well-being to ensure there is no immediate danger or risk of infection. Inspecting the cuts for debris is crucial to prevent infection and assess the severity of the self-inflicted wounds. Documenting the size and location of the cuts (choice A) can be done after ensuring the wounds are clean. Administering a tetanus antitoxin (choice C) is not necessary unless there is evidence of contamination with soil or rust. Implementing the client's behavioral modification plan (choice D) is important but not the priority when the client's physical health is at risk.