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 ["A","C","D"]
Explanation
Rationale:
A. Increased respiratory rate is a common finding in fluid overload due to pulmonary congestion and edema, which can affect breathing.
B. Increased temperature is not directly associated with fluid overload; it is more indicative of an infection or inflammatory process.
C. Increased heart rate can occur as the heart compensates for the increased blood volume and stress on the cardiovascular system.
D. Increased blood pressure is a typical response to fluid overload due to the higher volume of circulating blood.
E. Increased hematocrit is usually not associated with fluid overload; instead, it is often increased in conditions of dehydration or hemoconcentration.
Correct Answer is A
Explanation
Rationale:
A. Awareness of potential for self-harm is the priority as it directly impacts the safety and immediate well-being of the client with borderline personality disorder.
B. Medication compliance is important but secondary to immediate safety concerns.
C. Information about insurance coverage is relevant but does not address the immediate psychological safety needs.
D. Resources for group therapy are helpful but not as urgent as ensuring the family is aware of and can respond to self-harm risks.