A nurse in a community clinic is speaking to a parent who expresses concern for her adolescent son.
Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?

1. Answer and explanation The correct answers are:

Condition:

1. Mania Actions:
2. Daily weight

D. Suicidal behavior

Parameters to monitor:

Blood pressure and pulse rate

Food intake during meals

Rationale for condition:

Choice A: Mania

The client's presentation is consistent with the manic phase of bipolar disorder.

Key features of mania include:

Elevated mood or irritability

Increased energy and activity levels

Racing thoughts and rapid speech

Decreased need for sleep Impulsive behavior

Distractibility

Poor judgment

Grandiosity

Auditory hallucinations Rationale for actions:

Choice B: Daily weight

Weight loss is a common symptom of mania due to increased activity levels and decreased appetite.

Monitoring weight helps assess the severity of mania and the need for nutritional interventions.

Choice D: Suicidal behavior

Individuals with bipolar disorder are at increased risk for suicide, especially during manic episodes.

Close monitoring for suicidal ideation and behavior is crucial for safety.

Rationale for parameters to monitor:

Choice A: Blood pressure and pulse rate

Mania can lead to physiological changes such as increased heart rate and blood pressure.

Monitoring these vital signs helps assess the physical impact of mania and the potential need for medical interventions.

Choice C: Food intake during meals

As mentioned, decreased appetite is common in mania.

Monitoring food intake ensures adequate nutrition and prevents dehydration.

Choice A rationale:

Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.

It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.

It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.

Choice B rationale:

Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.

This information can be used to develop a safety plan and to help the client manage their symptoms.

It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.

Choice C rationale:

Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.

It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.

It can also damage the therapeutic relationship between the nurse and the client.

Choice D rationale:

Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.

While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.