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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason:
Aspiration is a significant risk for clients with acute alcohol intoxication due to an impaired gag reflex. Alcohol can depress the central nervous system, leading to a decreased level of consciousness and a diminished gag reflex, which increases the risk of aspiration of gastric contents into the lungs.
Choice B Reason:
Impaired coordination and judgment are common in acute alcohol intoxication, increasing the risk of injury. Alcohol affects the cerebellum, the part of the brain that regulates coordination and balance, as well as the frontal lobes, which are responsible for judgment and decision-making.
Choice C Reason:
Alcohol is metabolized by the liver, and excessive alcohol intake can lead to alcohol toxicity and liver impairment. Acute alcohol intoxication can cause hepatic steatosis, alcoholic hepatitis, and even acute liver failure in severe cases.
Choice D Reason:
Dizziness and an unsteady gait are direct effects of alcohol's impact on the vestibular system and the brain's ability to process spatial information, leading to an increased risk of falls.
Choice E Reason:
Alcohol intoxication can impair immune function, making the client more susceptible to infections. Alcohol disrupts immune pathways in complex ways, which can impair the body's ability to defend against infections
Correct Answer is B
Explanation
Choice A reason:
Caffeine is not typically associated with liver cirrhosis. While excessive consumption of caffeine can have various health implications, it is not considered a direct cause of liver cirrhosis. The liver metabolizes caffeine without significant damage or scarring to the liver tissue.
Choice B reason:
Alcohol is the primary cause of liver cirrhosis in many cases. Chronic alcohol abuse leads to liver damage and subsequent scarring, known as cirrhosis. The liver's function is to process and filter toxins, including alcohol. Excessive and prolonged alcohol consumption overwhelms the liver's ability to process it, leading to inflammation, damage, and eventually scarring of the liver tissue.
Choice C reason:
Inhalants are substances that produce chemical vapors that can be inhaled to induce a psychoactive, or mind-altering, effect. While they can cause a range of acute and chronic health issues, including damage to the heart, kidneys, lungs, and brain, they are not commonly associated with liver cirrhosis. Liver cirrhosis is not a typical consequence of inhalant use.
Choice D reason:
Cocaine use can lead to various health problems, including cardiovascular and neurological issues, but it is not commonly identified as a primary cause of liver cirrhosis. Cocaine metabolites can be toxic to the liver; however, the direct causation of cirrhosis from cocaine alone is less established compared to alcohol-related liver disease.
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