A teenager is noted to have a heightened awareness of reality, feelings of depersonalization, unpredictable and sometimes violent behavior, and flashbacks. The nurse suspects that the teenager is taking which of the following chemicals?

A. Ignore the incident since it is an attention-seeking behavior: Ignoring the incident is not appropriate because the client may be in distress or at risk of harm.
B. Stay with the group and ask another client to go and check on the situation: Asking another client to check on the situation is not appropriate, as it is the nurse's responsibility to ensure the safety of all clients.
C. Follow the client to determine the cause of the behavior: Following the client allows the nurse to assess and intervene appropriately to ensure the client's safety and address the cause of the behavior.
D. Ask the group what they think about the client's behavior: Discussing the behavior with the group is not appropriate in an emergency situation and does not address the immediate needs of the distressed client.

A. Inspect the client's personal belongings. Inspecting the client's personal belongings helps to ensure that the client does not have access to items that could be used for self-harm, such as sharp objects or medications.
B. Assign the client to a private room. Assigning a client who has attempted suicide to a private room can increase isolation and the risk of self-harm, as they are not easily observed.
C. Tuck bedcovers over client's hands and arms. This intervention is not effective and could potentially restrict the client's movement, increasing feelings of distress.
D. Remove utensils from the client's meal trays. Removing utensils, especially sharp ones, from meal trays helps to prevent the client from using them to harm themselves.