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.

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Correct Answer is C

Explanation

Choice A reason:
Escorting the client to the common area is not the priority action during a panic attack. The common area may have too much stimulation and could potentially worsen the client's anxiety. It is important to provide a quiet and safe environment for the client during a panic attack.

Choice B reason:
Contacting security for possible restraints is not the priority action and should only be considered if the client is a danger to themselves or others. Restraints can increase the client's anxiety and agitation, and the goal is to de-escalate the situation in a non-threatening manner.

Choice C reason:
Staying with the client is the priority action. The presence of a nurse can provide reassurance and a sense of safety. The nurse should use a calm and soothing voice, maintain a non-threatening posture, and stay with the client until the panic attack subsides. Offering support and using relaxation techniques can help the client regain control.

Choice D reason:
Staying away from the client is not the priority action. Isolation can increase the client's fear and anxiety. The nurse should remain with the client, offering reassurance and monitoring the client's condition throughout the panic attack.

A. "Alcohol tolerance causes me to have an increased effect when taking opiates." B. "I will develop a decreased physical response to alcohol." C. "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal." D. "Alcohol tolerance produces physical changes when I haven't recently ingested alcohol."

Correct Answer is B

Explanation

Choice A reason:
The statement "Alcohol tolerance causes me to have an increased effect when taking opiates" is incorrect. Alcohol tolerance refers to the body's diminished response to the effects of alcohol due to prolonged exposure. It does not directly affect the body's response to other substances like opiates. However, it's important to note that mixing alcohol with opiates can be dangerous and is generally advised against due to the risk of respiratory depression and other adverse effects.

Choice B reason:
The statement "I will develop a decreased physical response to alcohol" is correct and indicates effective teaching. As a person develops alcohol tolerance, their body requires more alcohol to achieve the same effects that were previously attained with less alcohol. This is due to physiological adaptations within the body, particularly in the liver and central nervous system, which become more efficient at metabolizing alcohol and less responsive to its effects.

Choice C reason:
The statement "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal" is incorrect. Alcohol tolerance itself is not a medical emergency; rather, it is a physiological adaptation to regular alcohol consumption. Withdrawal, on the other hand, can be a medical emergency if severe symptoms such as seizures or delirium tremens occur. Tolerance and withdrawal are related but distinct phenomena; tolerance can lead to dependence, which, when alcohol use is stopped, can result in withdrawal symptoms.

Choice D reason:
The statement "Alcohol tolerance produces physical changes when I haven't recently ingested alcohol" is misleading. Alcohol tolerance does not produce physical changes in the absence of alcohol. Instead, tolerance is characterized by a reduced response to alcohol when it is consumed. Physical changes, such as withdrawal symptoms, may occur when a person who has developed tolerance stops consuming alcohol, but these are not due to tolerance itself.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates that the teaching was effective?

Correct Answer is B

Explanation

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?

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

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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?

The nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal symptoms. Which of the following should be the priority action by the nurse?