A 18-year-old male client is admitted to the hospital with a possible drug overdose. His mother requests to know the results of the toxicology screen test. Which response is best for the nurse to provide?

A. Oxygen saturation 95% on room air A SpO2 of 95% is within acceptable limits, especially in a client who is not exhibiting signs of respiratory distress. This does not require immediate investigation, as it is not low enough to be concerning.

B. Bone misalignment: The client’s collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation that needs to be evaluated further to prevent further injury, ensure proper alignment, and determine the need for stabilization or surgical intervention.

C. Swelling at the site of injury: Swelling at the injury site, especially with a history of trauma, could indicate a fracture or soft tissue damage. The nurse should assess the extent of the swelling to rule out internal bleeding, compartment syndrome, or a fracture requiring urgent management.

D. Nausea and fatigue reported by client: Nausea and fatigue can be symptoms of more serious conditions, such as a concussion or internal bleeding, especially given the trauma to the head. These symptoms should be investigated to rule out any neurological or systemic involvement.

E. Decreased range of motion: The client’s decreased range of motion in the left arm, particularly with the reported intense pain, indicates a potential fracture, dislocation, or significant soft tissue injury. This needs to be further assessed to ensure proper treatment and avoid further complications.

F. Intense pain reported by client: The client reports intense pain (10 on a 0 to 10 scale) in the left arm, along with difficulty moving it. This is a critical symptom, suggesting a possible fracture, dislocation, or soft tissue injury that needs to be addressed immediately.

G. Left arm that is cool to touch: Coolness to the touch in the left arm could indicate a lack of adequate blood circulation, potentially from vascular injury or compression. This requires further evaluation to assess for possible arterial injury or compartment syndrome.

G. Blood pressure of 136/90 mm Hg: While 136/90 mm Hg is elevated for a general population, it is not an immediate life-threatening concern in this acute trauma setting. It could be a normal finding for someone with a history of hypertension, or a temporary elevation due to pain and anxiety from the injury.

A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.

B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.

C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.

D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.

E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.