A nurse is planning care for a client who is in the manic phase of bipolar disorder.

Which of the following interventions should the nurse include in the client's plan of care?.

A rationale:

Spending time with friends can be a protective factor against suicide, as it provides social support and connection.

While isolation can be a risk factor, spending time with friends does not inherently indicate suicide risk.

It's important to assess the quality of relationships and the presence of other risk factors.

Choice B rationale:

Regular sleep patterns often indicate healthy mental health.

Significant changes in sleep patterns (either too much or too little) can be warning signs, but consistent sleep of 9 hours is not typically a concern.

It's essential to evaluate sleep quality and any recent changes.

Choice C rationale:

Religious involvement can provide a sense of purpose, belonging, and support, which can be protective against suicide.

While it's not a guarantee of protection, it's generally a positive factor.

It's crucial to assess the individual's level of engagement and any potential conflicts within their religious beliefs.

Choice D rationale:

Exposure to suicide, especially in a close connection like a coach, can significantly increase a person's risk for suicide.

It can lead to normalization of suicide as a coping mechanism, imitation of behavior, or triggering of underlying mental health issues.

This is a strong risk factor that warrants immediate attention and assessment.

The correct answer is Choice C.

Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.

Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.

Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.

Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.