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 C
Explanation
Rationale:
A. Narrative therapy is a therapeutic approach that focuses on reshaping personal narratives and is not typically associated with increased risk of self-harm.
B. Dialectical behavior therapy (DBT) is specifically designed to help individuals with borderline personality disorder manage self-harm behaviors and emotional dysregulation, so it would generally reduce, not increase, risk.
C. The period following hospital discharge is often associated with a higher risk of self-harm due to potential lack of support, instability, or feelings of abandonment.
D. While significant life events such as getting married can be stressful, they are not typically associated with the highest risk of self-harm compared to the transitional phase post-discharge.
Correct Answer is B
Explanation
Rationale:
A. Placing a client with active tuberculosis in a room with another client increases the risk of airborne transmission of the infection, which is inappropriate for infection control.
B. A room with air exhaust directly to the outdoor environment is ideal for a client with active tuberculosis because it provides negative pressure, helping to contain and prevent the spread of the infectious airborne particles.
C. The ICU is typically reserved for critically ill patients requiring intensive monitoring and care, and it may not provide the necessary infection control measures for TB.
D. A room near the nurses' station would not ensure the negative pressure ventilation needed to prevent airborne transmission of tuberculosis.