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. A blood pressure of 102/66 mm Hg is within normal limits for a postoperative client.
B. Straw-colored urine is a normal finding for a postoperative client.
C. A respiratory rate of 18/min is within normal limits.
D. Yellow-green drainage from the surgical incision can indicate infection or other complications and should be reported to the provider for further evaluation.
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Asking about salary range is not directly relevant to the client’s mental health condition and would not help in understanding the barriers to employment.
B. Inquiring if the client has served time in prison may reveal a history that could impact their employability, as some employers may have restrictions on hiring individuals with criminal records.
C. Asking about the type of vehicle the client drives is not directly related to the client’s mental health or barriers to employment, and it would not provide insight into why the client is struggling to find work.
D. Asking about drug use is pertinent as substance abuse can interfere with employment opportunities and overall functioning.
E. Knowing whether the client is taking antipsychotic medication is important because adherence to treatment can significantly affect the client’s ability to function in a work environment.