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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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View Related questions

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.

Correct Answer is C

Explanation

Rationale:

A. Denial involves refusing to accept reality but is not as characteristic of borderline personality disorder as splitting.

B. Reaction formation involves behaving in a manner opposite to one's true feelings, which is not the primary defense mechanism in borderline personality disorder.

C. Splitting is a common defense mechanism in borderline personality disorder where the client views people or situations as all good or all bad, potentially causing conflict within the healthcare team.

D. Regression involves reverting to earlier developmental stages but does not typically cause division among healthcare providers.

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