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. Reviewing the client's history and reading progress notes are important for understanding the client's situation but are secondary to ensuring the nurse's readiness.
B. Reviewing current provider prescriptions is relevant but does not address the immediate need for self-preparation.
C. Performing self-reflection is essential to ensure that the nurse is emotionally prepared and empathetic, which is crucial when dealing with clients experiencing significant grief.
D. Performing self-reflection is the most critical first step as it ensures the nurse is emotionally prepared and able to provide empathetic and non-judgmental support to the client during a difficult time.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Protein intake should be limited in clients with CKD to reduce the burden on the kidneys, as excessive protein can accelerate kidney damage.
B. Caloric intake typically needs to be adequate to meet energy requirements, not necessarily limited unless advised by a healthcare provider based on specific health needs.
C. Sodium intake should be restricted to prevent fluid retention and hypertension, which can worsen kidney function.
D. Phosphorous should be limited to avoid hyperphosphatemia, which can lead to bone and cardiovascular problems in CKD patients.
E. Calcium intake is usually maintained or adjusted carefully, rather than broadly limited, to manage bone health and prevent complications associated with CKD.