A nurse is discussing bias issues in mental health with a newly licensed nurse. Which of the following statements should the nurse include in the discussion?

A. "The voices talk only at night when I'm trying to sleep."

This statement does not necessarily indicate a direct threat to the patient or others. It may be a manifestation of hallucination, but it doesn't explicitly pose a danger.

B. "The voices say everyone is trying to kill me."

This statement suggests paranoid delusions and a direct threat to the patient's safety. The nurse should implement safety measures to protect the patient and others from potential harm.

C. "I hear angels playing harps."

This statement describes a positive or benign hallucination, which may not require immediate safety measures. While it might be distressing for the patient, it doesn't pose an imminent danger.

A. Note escalating behaviors and intervene immediately:

This option prioritizes the client's safety by addressing escalating behaviors promptly. Bizarre behaviors, neologisms, and thought insertion may indicate a severe episode of psychosis, and timely intervention is crucial to prevent harm to the client or others.

B. Interpret attempts at communication:

While understanding and interpreting communication are important, in a situation with escalating behaviors and potential safety concerns, immediate intervention takes precedence. Communication interpretation can follow once the safety of the client has been ensured.

C. Assess for medication noncompliance:

Medication noncompliance can contribute to exacerbation of symptoms, but in an acute situation where safety is a concern, addressing immediate behaviors takes precedence. Medication assessment can be done in the context of a more comprehensive assessment after the immediate safety concerns have been addressed.

D. Assess triggers for bizarre, inappropriate behaviors:

Identifying triggers is important for understanding the underlying causes of the behavior, but in the context of escalating behaviors and potential safety issues, immediate intervention to de-escalate the situation is the priority. Triggers can be explored once the immediate safety concerns are addressed.