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?
A.
Implement the client’s behavioral modification plan
B.
Document the size and location of the cuts
C.
Administer a tetanus antitoxin.
D.
inspect the cuts for debris
The Correct Answer and Explanation is:
The correct answer is D. Inspect the cuts for debris.
Explanation:
When a client with bipolar disorder presents with fresh, self-inflicted cuts, the nurse must prioritize immediate safety and address the potential for infection or other complications. Here’s a detailed breakdown of why inspecting the cuts for debris should be the first action:
- Immediate Safety and Wound Care:
- The first priority is to ensure the client’s physical safety. Inspecting the cuts for debris is crucial because foreign material in the wounds can lead to infection. Proper wound inspection helps in determining the appropriate course of treatment, which may include cleaning the wound and administering a tetanus antitoxin if indicated.
- Assessment of the Injury:
- By examining the cuts, the nurse can assess the extent of the injury. This includes evaluating the depth, cleanliness, and any potential damage to underlying tissues. Identifying debris, such as dirt or fragments, is essential for preventing infection and promoting proper healing.
- Preventing Infection:
- Debris in a wound can serve as a medium for bacterial growth, leading to infections such as cellulitis or abscesses. Thoroughly inspecting and cleaning the wounds helps mitigate this risk. It is also an opportunity to assess whether the cuts require more intensive medical treatment.
- Subsequent Actions:
- After inspecting the cuts, the nurse can take other necessary actions. For instance, if the cuts are found to be clean and superficial, the nurse might proceed with documenting the size and location of the cuts (B) and assessing the need for a tetanus antitoxin (C). Behavioral modification plans (A) can be implemented after addressing the immediate physical needs and ensuring the client is stable.
In summary, the initial action of inspecting the cuts for debris addresses immediate physical safety and prevents further complications, such as infection. This step is fundamental before documenting, administering additional treatments, or implementing behavioral interventions.