ATI RN
ATI RN Mental Health Asn Questions
Extract:
Question 1 of 5
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: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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