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)

Necklace

Lace-up tennis shoes

Nylon ankle socks

Cotton underwear

A glass-framed picture

Answer and Explanation

Correct Answer : A,B,E

Choice A reason:
A necklace can pose a risk for clients with suicidal tendencies as it can be used to inflict self-harm. In an acute mental health unit, it is crucial to remove any items that could potentially be used in another suicide attempt. The nurse should ensure that the environment is safe and free from objects that could be used for hanging or strangulation.

Choice B reason:
Lace-up tennis shoes have laces that can be removed and used by the client to harm themselves. It is a standard safety precaution in mental health units to remove any items with strings or laces, such as belts, drawstrings, or shoe laces, to prevent their use in self-harm or suicide attempts.

Choice C reason:
Nylon ankle socks are generally considered safe and do not typically need to be removed. They do not pose a significant risk for self-harm. Therefore, the client can keep these for personal comfort and hygiene.

Choice D reason:
Cotton underwear is a basic necessity and does not present a risk for self-harm. It is important for the client's dignity and hygiene to have access to personal undergarments while in the mental health unit.

Choice E reason:
A glass-framed picture, while sentimental, poses a risk due to the glass, which can be broken and used to inflict self-harm. For safety reasons, any items made of glass or other breakable materials should be removed from the client's access in a mental health unit.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason:
While giving the family an opportunity to talk about their feelings is important, it is not the immediate priority for staff intervention following the incident. The family's needs are crucial, but the question specifically asks about the staff's follow-up actions.

Choice B reason:
Investigating and identifying cues in the client's behavior that might have indicated contemplation of suicide is a critical step in understanding and preventing future incidents. However, this is more of a retrospective action and not the immediate priority for staff intervention after such an event.

Choice C reason:
Providing professional counseling for staff members is the priority intervention. Staff members may experience a range of emotions, including grief, guilt, and trauma, following a client's suicide. Professional counseling can support staff in processing these feelings and prevent potential long-term psychological effects.

Choice D reason:
Changing policies for staff observation of clients who are suicidal may be necessary, but it is not the immediate priority following the incident. Policy review and changes are part of a longer-term strategy to improve care and prevent future incidents.

A. The client assumes an active role in her care planning process. B. The client identifies positive qualities about herself. C. The client exhibits expected grieving behaviors. D. The client makes a contract to avoid self-harm.

Correct Answer is D

Explanation

Choice A reason:
While it is beneficial for clients to be involved in their care planning, this is not the immediate priority. Active participation in care planning is a goal that can be pursued once the client's safety and stability are ensured.

Choice B reason:
Identifying positive qualities about oneself is an important step in improving self-esteem and promoting recovery in clients with major depressive disorder. However, this is not the most immediate priority when compared to ensuring the client's safety¹.

Choice C reason:
Exhibiting expected grieving behaviors is a natural and necessary process for healing after the loss of a loved one. However, the priority in the acute phase of care, especially when a client is at risk for self-harm, is to ensure safety.

Choice D reason:
The priority nursing goal for a client with major depressive disorder, especially following a significant loss, is to ensure safety. Making a contract to avoid self-harm is a critical intervention that addresses the risk of suicide, which is heightened in individuals with major depressive disorder and recent significant loss. This contract is a verbal or written agreement between the client and the healthcare provider that the client will not harm themselves and will seek help if they have thoughts of self-harm.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff on the unit as a follow-up to this incident?

Correct Answer is C

Explanation

A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

Correct Answer is D

Explanation

A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

A nurse is preparing to teach a client about the lithium prescription for treating bipolar disorder. Which of the following statements should the nurse include in the teaching?

A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis?

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

A nurse is caring for a client diagnosed with bipolar disorder in an acute manic state. The client is running around the unit asking people to dance with her. After ensuring safety, which of the following interventions should the nurse take?

A client diagnosed with major depressive disorder tells the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

A nurse is caring for a client who has been admitted with a suspected stimulant overdose. Which of the following nursing priorities should the nurse implement first?

A nurse is providing discharge teaching to a client diagnosed with bipolar disorder who will be discharged with a prescription for lithium. The nurse should teach the client that which of the following is a risk factor for lithium toxicity?