A nurse is assessing a client who is experiencing acute amphetamine toxicity. Which of the following findings should the nurse expect?

A. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to navigate their environment and complete activities safely. Providing extra time reduces stress, supports independence, and promotes a sense of autonomy while performing daily tasks.

B. Touch the client gently to announce presence: The nurse should announce presence verbally first. Touching without warning may startle the client.

C. Keep objects in the client's room in the same place: Maintaining a consistent arrangement of personal items prevents confusion and reduces the risk of falls or accidents. Predictable placement allows the client to perform tasks safely and maintain independence.

D. Approach the client from the side: Approaching from the side is not recommended because it may startle the client. Best practice is to approach from the front while using verbal cues to announce your presence and provide orientation.

E. Ensure there is high-wattage lighting in the client's room: High-intensity lighting may cause glare and discomfort for clients with vision loss, especially those with conditions like macular degeneration. Adequate but non-glare lighting is preferable to support safe mobility.

Rationale for correct choices

• Thoughts of self‑harm: The client recently experienced multiple major stressors, loss of a job and the end of a long-term relationship, while displaying flat affect, tearfulness, withdrawal, and refusal to eat. These changes, combined with the statement, “My life is a mess,” indicate worsening depression and internal distress. These findings elevate the risk for self‑harm and require immediate monitoring.

• Hopelessness: The client’s statements reflect feelings of worthlessness and an inability to see a path forward, which are hallmark signs of hopelessness. Their withdrawal, refusal to eat, and persistent tearfulness reinforce that they are overwhelmed and unable to cope with current stressors. Hopelessness is closely linked with suicidal ideation, explaining the elevated self‑harm risk.

Rationale for incorrect choices

• Anorexia nervosa: Although the client is refusing meals, this refusal occurs in the context of emotional distress rather than weight‑loss motivation or body‑image disturbance. The client’s BMI is low but not critically low, and there is no fear of gaining weight or distorted self‑perception. Appetite changes are common in depression and better explained by mood not eating disorders.

• Acute dystonic reaction: Acute dystonia is associated with antipsychotic medications, not sertraline, which the client is currently taking. No signs such as muscle spasms, stiff neck, or oculogyric crisis are present. The client’s symptoms are emotional and cognitive, not neuromuscular.

• Refusal to eat: While refusal to eat is concerning, it alone does not most strongly indicate risk for self‑harm. Poor appetite is common in depression and may reflect low motivation or energy. It lacks the direct emotional connotation that hopelessness carries in predicting self‑harm.

• Family history: A family history of major depressive disorder increases long‑term vulnerability but does not explain the client’s immediate risk situation. The client’s current behaviors and statements provide more immediate clinical evidence than hereditary factors. Family history does not sufficiently reflect the acute emotional state contributing to self‑harm risk.