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 B
Explanation
Rationale:
A. Stage 2 (moderate) of alcohol withdrawal involves symptoms such as increased blood pressure and heart rate, mild confusion, and tremors, but does not typically include hallucinations or severe agitation.
B. Stage 3 (severe) alcohol withdrawal includes severe symptoms such as hallucinations (e.g., seeing spiders), severe agitation, and possible delirium tremens, which are consistent with the client's manifestations.
C. Stage 1 (mild) symptoms generally include mild anxiety and tremors but do not include hallucinations or significant changes in mental status.
D. The client’s manifestations indicate severe withdrawal symptoms, not just a general description.
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.