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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.)

A.

Nylon socks

B.

Glass framed picture of the client's partner

C.

Lace-up tennis shoes

D.

Cotton underwear

E.

Necklace

Question Solution

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 B

Explanation

Rationale:

A. This response incorrectly defines suicide attempts and self-harm and oversimplifies the concept of self-harm.

B. A suicide attempt involves self-harm with the intent to die, whereas self-harm (or self-injury) involves harming oneself without the intention of death. This response accurately differentiates between the two.

C. Suicide attempts can involve self-harm, but not all self-harm is intended as a suicide attempt. This response conflates the terms.

D. The terms are not interchangeable; understanding their differences is crucial for accurate assessment and intervention.

Correct Answer is D

Explanation

Rationale:

A. Action involves actively making changes or implementing strategies to alter behavior. The client's refusal to follow dietary advice indicates they are not actively engaging in behavior change.

B. Preparation entails planning and getting ready to make a change. The client’s statement shows no intention of preparing for a change.

C. Contemplation involves recognizing the need for change and considering it but not yet committed to making it. The client’s dismissive attitude suggests they are not at this stage.

D. Precontemplation is characterized by a lack of awareness or denial of the need for change. The client’s indifference to the dietary recommendations reflects this stage, as they are not yet considering changing their behavior.

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