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. "This medication may increase your blood pressure."

This statement is incorrect. Risperidone is not typically associated with significant increases in blood pressure. One of the potential side effects of risperidone is orthostatic hypotension, which is a drop in blood pressure when changing positions (e.g., standing up quickly). Therefore, this choice is not the best instruction to include in the teaching.

B. "Flu-like symptoms are an expected adverse effect of this medication."

This statement is incorrect. While risperidone can have side effects, flu-like symptoms are not commonly associated with it. Common side effects of risperidone may include dizziness, drowsiness, weight gain, and movement disorders. Flu-like symptoms are not a typical adverse effect of this medication.

C. "Avoid becoming overheated while taking this medication."

This statement is correct. Risperidone, like many other antipsychotic medications, can interfere with the body's ability to regulate temperature. This can lead to an increased risk of overheating, especially in hot weather or during vigorous physical activity. Therefore, it's important for patients taking risperidone to be cautious and avoid becoming overheated, as this could potentially lead to heat-related complications.

D. "Muscle twitches can occur the first few weeks while taking this medication."

This statement is incorrect. Muscle twitches are not a common side effect of risperidone. While it's true that some movement disorders can occur with antipsychotic medications, the statement is too specific to muscle twitches and does not accurately reflect the typical side effect profile of risperidone.

A. Discuss the problem in a community meeting with the other clients on the unit present.

While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.

B. Escort the client to her room each time the nurse observes the client socializing with other clients.

This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.

C. Talk to the client and identify the specific limits that are required of the client's behavior.

This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.

D. Tell the other clients to ignore the client's lies.

While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.