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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View Related questions
Correct Answer is A
Explanation
Rationale:
A. Cognitive behavioral therapy (CBT) is a noninvasive, evidence-based treatment for depression. It helps clients identify and change negative thought patterns and behaviors that contribute to their depression.
B. Deep-brain stimulation is an invasive procedure used for treatment-resistant depression and other neurological conditions.
C. Electroconvulsive therapy (ECT) is a noninvasive but more intensive treatment often used for severe or treatment-resistant depression. However, it is generally not the first line of treatment.
D. Vagal nerve stimulation is a more invasive treatment, typically reserved for cases where other treatments have failed.
Correct Answer is B
Explanation
Rationale:
A. While inappropriate clothing might indicate a need for assessment of the client’s awareness or physical comfort, it is not as immediate a concern as the client's behavior.
B. The comment to the nurse is concerning as it may indicate disorganized thinking or potential for inappropriate behavior, which requires immediate attention for safety and therapeutic intervention.
C. A heart rate of 102/min is slightly elevated but not the most urgent issue compared to the client's behavior.
D. Elevated blood pressure should be monitored, but the priority is the client’s inappropriate behavior, which may affect safety.