A nurse is reviewing the medical record of a 50-year-old male client who has schizophrenia in an inpatient mental health facility

Exhibits

Which of the following findings should the nurse report to the provider? (Select all that apply.)

Choice A rationale

Implementing 24-hr one-to-one nursing observation is a necessary precaution for a newly admitted adolescent who overdosed on prescription pain medication. This close monitoring allows for continuous assessment of the client's physical and mental status, early detection of any complications, and prevention of further self-harm attempts, especially given the prescriptions for an anxiolytic and an SSRI, which could have delayed or paradoxical effects in an overdose situation.

Choice B rationale

Restricting interactions with other clients might increase the adolescent's feelings of isolation and depression, which could be counterproductive to their mental health recovery. Therapeutic interactions with peers can be beneficial.

Choice C rationale

Documenting the client's behavior every 2 hr is a standard nursing practice, but it is not sufficient for a client at high risk for self-harm following an overdose. Continuous observation provides immediate intervention capability.

Choice D rationale

Administering prescribed medication via the IM route is not necessarily a standard precaution for an overdose. The route of administration depends on the specific medication and the client's condition. Oral administration is usually preferred when the client is stable and can tolerate it.

Choice A rationale

Diazepam is a benzodiazepine, typically used for anxiety, muscle spasms, and seizures. While it has a calming effect, it does not directly address opioid use disorder and carries a risk of misuse and dependence, potentially exacerbating the client's condition.

Choice B rationale

Phenobarbital is a long-acting barbiturate used to control seizures. It is not a primary treatment for opioid use disorder and has a high potential for dependence and serious withdrawal symptoms if discontinued abruptly.

Choice C rationale

Buprenorphine is a partial opioid agonist that binds to opioid receptors in the brain, reducing cravings and withdrawal symptoms without producing the full euphoric effects of other opioids. It is a key medication in medication-assisted treatment (MAT) for opioid use disorder, helping clients manage their addiction and transition to recovery.

Choice D rationale

Chlordiazepoxide is another benzodiazepine, primarily used for anxiety and alcohol withdrawal. Similar to diazepam, it does not directly treat opioid use disorder and carries a risk of dependence and misuse in individuals with substance use disorders.