Choice A reason: Vomiting may occur in narcotic withdrawal, but seizures and loss of consciousness are more characteristic of severe withdrawal from other substances like alcohol or benzodiazepines. Narcotic withdrawal typically presents with agitation, sweating, and gastrointestinal symptoms, not primarily neurological collapse, making this less accurate for documenting suspected opioid withdrawal in this adolescent.

Choice B reason: Hypotension and shallow respirations are not typical of narcotic withdrawal; they suggest overdose or other conditions. Dilated pupils occur in withdrawal, but agitation and sweating are more prominent. This combination does not fully capture the autonomic and gastrointestinal symptoms of opioid withdrawal, making it incorrect for documentation.

Choice C reason: Agitation, sweating, and abdominal cramps are hallmark signs of narcotic withdrawal, reflecting autonomic hyperactivity and gastrointestinal distress due to opioid cessation. These symptoms align with the clinical presentation of opioid withdrawal in an adolescent with needle marks, supported by addiction medicine evidence, making this the best choice for documentation.

Choice D reason: Depression, fatigue, and dizziness may occur in later withdrawal phases but are less specific than agitation, sweating, and cramps, which are acute and prominent in early narcotic withdrawal. These symptoms are too vague to capture the immediate autonomic response, making this incorrect for documenting suspected opioid withdrawal.

Choice A reason: Decreased bowel movements (constipation) are a common side effect of benztropine due to its anticholinergic properties, but they do not indicate worsening EPS or treatment failure. Increased mouth movements suggest persistent or worsening EPS, requiring further evaluation, making constipation less critical for immediate reassessment.

Choice B reason: Decreasing hand tremors indicate benztropine’s effectiveness in treating EPS, as it reduces parkinsonian symptoms like tremors. This is a desired outcome, not a cause for further evaluation. Increased mouth movements, suggesting tardive dyskinesia or EPS persistence, are more concerning, making this incorrect.

Choice C reason: Increased mouth movements, such as tardive dyskinesia or dystonia, suggest worsening or inadequately controlled EPS, potentially indicating benztropine’s ineffectiveness or a need for dose adjustment. This finding warrants further evaluation, aligning with psychopharmacology evidence for monitoring anticholinergic therapy, making it the correct choice.

Choice D reason: Dry mouth is a common anticholinergic side effect of benztropine, not an indicator of EPS worsening. It is expected and manageable, unlike increased mouth movements, which signal potential EPS complications. This finding does not require immediate evaluation, making it incorrect for further nursing assessment.

Choice A reason: Progressive exposure to crowds is part of desensitization but is not the highest priority initially. Without trust and a safe environment, exposure may overwhelm the client, hindering therapy. Establishing trust ensures the client feels secure to engage in desensitization, making this less immediate than building rapport.

Choice B reason: Substituting positive thoughts helps manage anxiety but is secondary to establishing trust. Without a safe, trusting environment, cognitive strategies may be ineffective for a client with agoraphobia. Trust facilitates engagement in therapy, making this intervention less critical than creating a calm, supportive setting initially.

Choice C reason: Establishing trust by providing a calm, safe environment is the highest priority, as it builds the foundation for desensitization therapy. For agoraphobia, feeling secure enables the client to engage in exposure and cope with anxiety, aligning with psychiatric nursing principles for anxiety disorder management.

Choice D reason: Deep breathing is a useful coping strategy for anxiety but is less critical than establishing trust. Without a safe environment, the client may not feel secure enough to practice techniques during crowd exposure. Trust is foundational for therapeutic success, making this intervention secondary.

Choice A reason: Lethargy and depression are more typical of cocaine withdrawal or post-use crash, not active use. Recent cocaine use causes stimulation, euphoria, and dilated pupils due to sympathetic activation. These symptoms are less prominent during intoxication, making this incorrect for documenting acute cocaine effects.

Choice B reason: Cocaine, a stimulant, causes sympathetic activation, leading to stimulation (e.g., agitation, euphoria) and dilated pupils. These are hallmark signs of recent use, observable in the client’s presentation. This aligns with toxicology evidence for cocaine intoxication, making it the correct choice for nursing documentation.

Choice C reason: Bradycardia and bradypnea are not associated with cocaine use, which causes tachycardia and increased respiratory rate due to stimulation. These findings suggest opioid effects or other conditions, not cocaine intoxication, making this incorrect for documenting the client’s recent cocaine use observations.

Choice D reason: Hallucinations and delusions may occur with chronic or high-dose cocaine use but are less common than stimulation and dilated pupils in recent use. These psychiatric symptoms are not primary indicators of acute intoxication, making this less accurate for routine documentation of cocaine effects.

Choice A reason: Current weight is relevant for monitoring but not critical before starting sertraline. Medication history is more important to avoid drug interactions, as sertraline affects serotonin levels. Weight changes may occur during treatment, but they are not a primary concern for initiation, making this incorrect.

Choice B reason: Medication history is critical before starting sertraline to identify potential drug interactions, especially with MAOIs, SSRIs, or other serotonergic drugs, which can cause serotonin syndrome. This ensures safe prescribing, aligning with psychopharmacology guidelines, making it the most important information to obtain prior to initiation.

Choice C reason: Heart disease history is relevant but less critical than medication history for sertraline, which has minimal cardiac effects. Drug interactions pose a greater immediate risk, particularly with serotonergic agents. This choice is secondary, as cardiac concerns are not the primary consideration for sertraline initiation.

Choice D reason: Familial history of mental illness may guide diagnosis but is not essential for starting sertraline. Medication history directly impacts safety due to interaction risks. Family history is less urgent, making this incorrect compared to the immediate need to assess current medications for safe antidepressant use.

Choice A reason: Compulsive, ritualistic behaviors are characteristic of obsessive-compulsive disorder, not schizophrenia. Schizophrenia involves disorganized thinking, often manifesting as illogical responses. Ritualistic behaviors are less typical, making this incorrect for identifying a behavior characteristic of schizophrenia in an acute care setting.

Choice B reason: Illogical answers reflect disorganized thinking, a core symptom of schizophrenia, particularly in acute phases. This is due to impaired thought processes, a hallmark of the disorder, aligning with psychiatric diagnostic criteria. This behavior is characteristic and observable during admission assessment, making it the correct choice.

Choice C reason: Suicidal thoughts may occur in schizophrenia but are not specific to it, as they appear in many psychiatric conditions. Illogical responses are more characteristic of schizophrenia’s cognitive disorganization. This choice is less precise, making it incorrect for a defining schizophrenia behavior.

Choice D reason: Depression followed by euphoria suggests bipolar disorder, not schizophrenia. Schizophrenia involves persistent psychotic symptoms like disorganized thinking, not mood swings. Illogical answers better represent schizophrenia’s thought disorder, making this incorrect for a characteristic behavior in an acute care schizophrenia admission.

Choice A reason: Identifying effective coping strategies is critical for an adolescent with suicidal ideation triggered by anger, as it addresses the root cause of the suicide attempt. This goal promotes emotional regulation and prevents future self-harm, aligning with psychiatric nursing priorities for suicide risk management.

Choice B reason: Attending group sessions supports socialization but does not directly address the client’s suicidal behavior or emotional triggers. Coping strategies are more critical to prevent recurrence of self-harm, making this goal less important than learning to manage feelings effectively in this context.

Choice C reason: Positive staff interaction fosters therapeutic alliance but does not target the client’s suicidal ideation or anger management. Developing coping skills is more critical to address the underlying emotional dysregulation, making this goal secondary to learning effective strategies for handling intense feelings.

Choice D reason: Expressing anger towards family may escalate conflict without resolving the client’s suicidal behavior. Teaching coping strategies is more important to manage emotions safely, preventing further self-harm. This goal is less therapeutic and potentially harmful, making it incorrect for priority care planning.

Choice A reason: Hydromorphone, an opioid, is used for pain, not delirium tremens (DTs), which requires benzodiazepines to manage withdrawal symptoms like tremors and seizures. Opioids may worsen respiratory depression in alcohol withdrawal, making this incorrect for treating DTs in this client with high alcohol levels.

Choice B reason: Lorazepam, a benzodiazepine, is the standard treatment for delirium tremens, as it reduces agitation, seizures, and autonomic instability in alcohol withdrawal. Its PRN use is appropriate for managing DTs symptoms, aligning with addiction medicine guidelines, making it the correct choice for this client.

Choice C reason: Prochlorperazine, an antiemetic, treats nausea but not DTs, which involves severe neurological and autonomic symptoms. Benzodiazepines like lorazepam are needed to prevent seizures and calm withdrawal. This medication is inappropriate, making it incorrect for managing alcohol withdrawal complications.

Choice D reason: Chlorpromazine, an antipsychotic, may lower seizure threshold, worsening DTs. Benzodiazepines like lorazepam are first-line for alcohol withdrawal to manage symptoms safely. Chlorpromazine is not indicated, making this incorrect for treating delirium tremens in a client with alcohol-related withdrawal.

Choice A reason: Fear of large dogs is a specific phobia, not a core schizophrenia symptom requiring provider notification. Social withdrawal indicates worsening negative symptoms or relapse, which is more critical. This fear is less concerning, making it incorrect for behaviors necessitating immediate healthcare provider contact.

Choice B reason: Changes in appetite are nonspecific and may occur in many conditions, not necessarily indicating schizophrenia relapse. Social withdrawal is a more specific negative symptom signaling potential decompensation, making it a priority for notification. Appetite changes are less urgent, making this incorrect.

Choice C reason: Social withdrawal is a key negative symptom of schizophrenia, often signaling relapse or worsening illness. Instructing the family to notify the provider ensures timely intervention, aligning with psychiatric management guidelines. This behavior is critical to monitor, making it the correct choice for discharge teaching.

Choice D reason: Decreased attention to detail may occur in schizophrenia but is less specific than social withdrawal, which strongly indicates negative symptom progression. Attention issues are harder to quantify and less urgent, making this incorrect compared to withdrawal as a priority behavior for provider notification.

Choice A reason: Administering a PRN sedative is inappropriate for echolalia, a non-emergent symptom of schizophrenia. Sedation does not address the behavior and may cause oversedation. Escorting to a private area reduces disruption without medication, aligning with least restrictive interventions, making this incorrect.

Choice B reason: Avoiding recognition of echolalia may ignore the client’s needs and fail to address unit disruption. Escorting to a private area de-escalates the situation while maintaining engagement, offering a therapeutic response. Ignoring the behavior is less effective, making this incorrect for managing echolalia.

Choice C reason: Escorting the client to a private area minimizes disruption to others while providing a calm environment to address echolalia. This intervention reduces stimuli and supports the client therapeutically, aligning with psychiatric nursing principles for managing schizophrenia symptoms, making it the best choice for this scenario.

Choice D reason: Isolating the client is overly restrictive and may exacerbate schizophrenia symptoms like paranoia. Escorting to a private area is less isolating, maintaining therapeutic engagement while addressing unit dynamics. Isolation is not patient-centered, making this incorrect compared to a supportive, de-escalating intervention.