A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?

A. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."

While it's important to consider the client's preferences, dietary restrictions are often in place for specific health reasons. Trying to incorporate forbidden foods into the diet plan might compromise the client's health and recovery.

B. "Why would you want to put your partner's health at further risk?"

This response is confrontational and may not foster a productive conversation with the partner. It's important to address the situation professionally and collaboratively.

C. "Everyone likes food from home, but it can delay your partner's recovery."

While this response acknowledges the partner's feelings, it's essential to communicate more directly about involving the healthcare provider in decisions about the client's diet.

"D. You will need to discuss your concerns about your partner's diet with the provider."

Explanation: In matters involving a client's dietary plan and health, it's important to involve the healthcare provider to make informed decisions. The nurse should guide the partner to communicate their concerns with the provider who has the authority to evaluate the situation, consider the dietary restrictions, and make a decision that aligns with the client's health and recovery.

A. "I need to make sure that the potential victim is warned."

Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.

B. "I need to keep the information confidential due to the client's right to privacy."

Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.

C. "I can only discuss the client's threats with a court order."

Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.

D. "I should verbally report this information to the psychiatrist."

Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.