A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home? (Select All that Apply.)
Nylon socks
Glass framed picture of the client's partner
Lace-up tennis shoes
Cotton underwear
Necklace
Correct Answer : B,C,E
Rationale:
A. Nylon socks are generally not considered a risk for self-harm and can be safely kept with the client.
B. A glass-framed picture presents a risk as the glass could be broken and used for self-harm. This item should be taken home.
C. Lace-up tennis shoes have long laces that could be used for self-harm, making them unsafe for a client at risk of suicide.
D. Cotton underwear does not pose a significant risk for self-harm and can be kept with the client.
E. A necklace could be used for self-harm, such as strangulation, and should be taken home to ensure the client's safety.
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Correct Answer is ["A","B","E"]
Explanation
Rationales:
A. The client's statement, "I can't go on living without my child," indicates a potentially serious risk to their safety and well-being. This statement suggests that the client may be experiencing suicidal ideation or extreme despair, which requires immediate attention and intervention.
B. While sadness and anger are expected components of grief, the intensity of these feelings and their persistence need to be assessed for any signs of complicated grief or potential for self-harm. Addressing these emotions is critical to ensuring the client’s safety and providing appropriate support.
C. While understanding the expectations during group meetings is important for therapy, it is not as immediately critical as addressing the client's statements about their outlook on living and their medication adherence.
D. Knowledge about the therapist’s role is important for therapeutic alliance, but it is less urgent compared to addressing the client’s potentially dangerous outlook on living and their medication issues.
E. The client’s refusal to take the prescribed medication, with the belief that it "will not help," indicates a possible issue with medication adherence or effectiveness. This needs to be addressed to ensure that the client is receiving appropriate treatment for their mental health needs.
Correct Answer is ["C","E","F"]
Explanation
Rationale:
A. Defense mechanisms and coping strategies are not the same. Defense mechanisms are unconscious processes used to protect the individual from anxiety and internal conflicts, while coping strategies are conscious efforts to handle stress.
B. Defense mechanisms can be maladaptive and may not always help clients positively deal with stress. They can sometimes hinder adaptive functioning.
C. Defense mechanisms are indeed influenced by neurological and psychological growth. As individuals age, they develop more sophisticated and adaptive mechanisms.
D. Maladaptive defense mechanisms do not improve mental well-being; instead, they can often worsen mental health and impair functioning.
E. Adaptive defense mechanisms, such as sublimation and rationalization, help individuals manage stress more effectively and transform challenges into manageable situations.
F. Adaptive defense mechanisms are characteristic of more mature psychological functioning, reflecting a higher level of emotional resilience and coping.