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 C
Explanation
Rationale:
A. Reporting the incident to other RNs on the shift does not ensure that the appropriate actions will be taken to address the issue.
B. Agreeing not to report the incident in exchange for the coworker seeking treatment is unethical and does not follow the correct reporting protocol.
C. Reporting the incident to the appropriate person in the chain of communication, such as a supervisor or nurse manager, is the correct course of action. This ensures that the situation is handled according to hospital policy and legal requirements, protecting patient safety and addressing the coworker's substance use disorder.
D. Agreeing not to report the incident if the coworker promises to report themselves is also unethical and fails to meet professional responsibilities.
Correct Answer is D
Explanation
Rationale:
A. Platelets at 150,000/mm3 are within the lower range of normal but not immediately concerning.
B. A positive Western blot test is confirmatory for HIV but is not an immediate concern compared to other lab values.
C. A WBC count of 5,000/mm3 is within normal limits and not a primary concern for an HIV-positive client.
D. A CD4-T-cell count of 180 cells/mm3 indicates advanced immunosuppression, which is critical to monitor in HIV-positive clients to assess the progression of the disease and the risk for opportunistic infections.