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 D
Explanation
Rationale:
A. Contacting the provider for directions may be necessary in some cases, but it does not directly demonstrate grief-informed care, which involves understanding and addressing the emotional needs of the grieving client.
B. Supporting the client's privacy is important, but avoiding discussions about the loss may prevent the client from processing their grief, which is not aligned with grief-informed care.
C. Standing while speaking and keeping the door open can make the client feel uncomfortable or unsupported during a vulnerable time. Grief-informed care emphasizes creating a supportive and empathetic environment.
D. Acknowledging and recognizing that the client has experienced a loss is a key component of grief-informed care. It validates the client's feelings and opens the door for further support and therapeutic interventions.
Correct Answer is D
Explanation
Rationale:
A. Seizures and tremors can occur with some antipsychotic medications but are not specifically indicative of tardive dyskinesia.
B. Hallucinations and delusions are symptoms of psychosis, not a side effect of anti-psychotic medications.
C. Nausea and vomiting can be side effects of anti-psychotic medications but are not characteristic of tardive dyskinesia.
D. Tardive dyskinesia is characterized by uncontrolled, repetitive movements, such as facial grimacing, tongue protrusion, and other involuntary movements.