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. The medication administration record is important for verifying the order but should be used in conjunction with the patient’s identification.
B. The order sheet provides the details of the blood product to be administered but is not the primary source for verifying patient identity.
C. The chart includes medical history and orders but does not provide direct patient identification for blood administration.
D. The identification wristband is the primary and most direct method for verifying the patient’s identity to ensure that the correct blood product is administered to the correct patient.
Correct Answer is B
Explanation
Rationale:
A. Narcissistic personality disorder involves a grandiose sense of self-importance and a need for admiration, but it is not typically associated with aggressive behavior in public settings.
B. Antisocial personality disorder is characterized by a disregard for the rights of others, impulsivity, and aggressive behavior. Clients with this disorder may engage in unlawful activities and show no remorse for their actions, making this the most likely diagnosis for the client described.
C. Histrionic personality disorder involves attention-seeking behavior and emotionality, but it does not typically manifest in aggressive outbursts.
D. Borderline personality disorder involves instability in relationships, self-image, and emotions, and while it may include impulsivity, it is not primarily associated with aggressive behavior in public settings.