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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Identifying the client's support systems is an important aspect of the assessment, as support systems can play a crucial role in the client's recovery. However, it is not the highest priority during the initial assessment. Support systems can provide emotional, social, and sometimes financial assistance, which can be beneficial in managing a situational crisis.
Choice B reason:
Identifying the client's coping skills is also important because it helps the nurse understand how the client typically deals with stress and crises. Coping skills are mechanisms that individuals use to manage stressful situations and can include problem-solving, seeking support, and using relaxation techniques. However, this is not the highest priority during the initial assessment.
Choice C reason:
Asking the client to identify the cause of the crisis can provide valuable information about the client's perspective and insight into the situation. Understanding the cause can help in planning appropriate interventions. However, this is not the highest priority during the initial assessment, especially if the client is not in a stable condition to discuss the crisis.
Choice D reason:
Determining if the client has psychotic thinking, is the highest priority. Psychotic thinking can include delusions, hallucinations, and disorganized thoughts, which may indicate a severe mental health condition that requires immediate attention. It is essential to assess for psychotic symptoms to ensure the safety of the client and others, as well as to determine the need for urgent psychiatric intervention.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:
Cirrhosis is a severe scarring of the liver and poor liver function seen at the terminal stages of chronic liver disease. It is one of the primary long-term effects of alcohol use disorder, as the liver is the main organ responsible for metabolizing alcohol. Chronic alcohol consumption can lead to inflammation, liver cell death, and eventually cirrhosis, which significantly impairs the liver's ability to function properly.
Choice B reason:
Heightened awareness is not typically a long-term physiological effect of alcohol use disorder. In fact, chronic alcohol use is more likely to dull cognitive functions and reduce awareness due to its depressive effects on the central nervous system.
Choice C reason:
Gastritis, an inflammation of the stomach lining, is another potential long-term effect of alcohol use disorder. Alcohol can irritate and erode the gastric mucosa, leading to gastritis, which may present with symptoms such as abdominal pain, nausea, and vomiting.
Choice D reason:
Brain damage is a serious long-term effect of alcohol use disorder. Alcohol can cause changes in the brain, leading to problems with cognition, memory, and motor skills. Chronic exposure to alcohol can result in brain shrinkage and the development of conditions like Wernicke-Korsakoff syndrome.
Choice E reason:
Esophageal varices are enlarged veins in the esophagus that can occur as a result of portal hypertension, often due to cirrhosis of the liver caused by alcohol use disorder. They are a significant risk because they can rupture and lead to life-threatening bleeding.
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