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
Explanation
Rationale:
A. The primary criterion for removing restraints is that the client must be calm and cooperative, indicating that the immediate safety concern has been addressed.
B. Verbalizing remorse is not a requirement for removing restraints; the focus is on the client's behavior and cooperation.
C. The provider does not need to be present for the nurse to assess the client's readiness for removal of restraints, although provider orders and assessments are important.
D. Simply verbalizing anger does not indicate that the restraints can be removed; the client must demonstrate appropriate behavior and cooperation.
Correct Answer is A
Explanation
Rationale:
A. Dental decay is a common result of frequent vomiting in bulimia nervosa due to exposure of teeth to stomach acid.
B. Bulimia nervosa often involves fluctuations in weight rather than a consistently lower weight, as it includes binge eating episodes.
C. Hypokalemia (low potassium) is more commonly associated with bulimia due to vomiting rather than hyperkalemia (high potassium).
D. Amenorrhea (absence of menstruation) may occur in bulimia nervosa but is less specific than dental decay for the condition.