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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.)

A.

Nylon socks

B.

Glass framed picture of the client's partner

C.

Lace-up tennis shoes

D.

Cotton underwear

E.

Necklace

Question Solution

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 B

Explanation

Rationale:

A. Removing the PICC line should only be done if directed by a provider after further assessment.

B. The first action is to measure the circumference of both arms to assess for possible complications such as thrombosis or infiltration. This measurement will help determine the extent of the swelling and inform subsequent actions.

C. Notifying the provider is important but should be done after gathering relevant assessment data, such as the arm circumference.

D. Applying a cold pack may be appropriate for reducing swelling but is not the first step. Assessment should come first.

Correct Answer is C

Explanation

Rationale:

A. Observing the final 2 minutes is not sufficient for detecting acute transfusion reactions, which can occur at any time during the transfusion.

B. Observing the final 15 minutes is also not adequate; reactions can occur earlier.

C. The first 15 minutes is the most critical time for observing for transfusion reactions, as most reactions occur during this period.

D. The first 2 minutes are too brief to detect potential transfusion reactions, which typically manifest within the first 15 minutes.

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