A 26-year-old client is brought to the emergency room by a friend.

The client is unable to give any coherent history.

Which response should the nurse provide when the client's friend offers to provide information regarding the client?

Choice A rationale

Serotonin 5HT_2 receptors are targeted by many atypical antipsychotics and mood stabilizers. Blocking these receptors is associated with desired effects like improved mood and reduced psychosis, but also with side effects like weight gain or hypotension. It is not the primary mechanism responsible for dry mouth, constipation, and blurred vision, which are characteristic anticholinergic effects.

Choice B rationale

Acetylcholine (ACh) receptors, specifically muscarinic receptors, are blocked by many psychotropic drugs, especially older antidepressants and antipsychotics. This anticholinergic action inhibits parasympathetic nervous system responses, leading to the classic peripheral side effects: dry mouth (xerostomia), constipation (decreased peristalsis), and blurred vision (mydriasis/cycloplegia), which are directly mediated by ACh blockade.

Choice C rationale

Alpha-1 (α_1) adrenergic receptors are blocked by many psychotropic agents, especially antipsychotics. Blocking these receptors causes vasodilation and is primarily associated with orthostatic hypotension (dizziness upon standing) and reflex tachycardia. While it may sometimes contribute to overall side effect burden, it is not the direct cause of the triad of dry mouth, constipation, and blurred vision.

Choice D rationale

Histamine (H_1) receptors are blocked by many psychotropic drugs, particularly those with sedative properties. This blockade primarily leads to side effects such as sedation, drowsiness, and weight gain. While it contributes to the overall side effect profile, it is not the main pharmacological mechanism responsible for the distinct cluster of dry mouth, constipation, and blurred vision symptoms.

Choice A rationale

While improved language use (e.g., fluency, confidence) is a necessary component for resolving the underlying reason for the social withdrawal, an outcome should be a measurable behavioral change or demonstrable action. Improving language skills is an antecedent step or a parallel goal, not the direct, observable behavioral goal of "Impaired social interaction.”.

Choice B rationale

Increased independence in decision making is a worthy goal related to autonomy, but it does not directly address the social interaction component of the nursing diagnosis. The core problem identified is the lack of participation in group settings due to the stated sociocultural conflict, requiring an outcome focused on behavioral engagement.

Choice C rationale

Improved social skills is a broad concept; the client's stated issue is a specific linguistic barrier, not necessarily a deficit in general social etiquette or reciprocal conversation skills. A behavioral outcome must be highly specific and directly linked to the evidence (not participating due to language difficulty) provided in the nursing diagnosis.

Choice D rationale

This outcome is the most measurable and directly addresses the impaired social interaction evidenced by non-participation. Selecting and participating in one group activity per day is a clear, time-bound behavioral goal that requires the client to overcome the stated barrier and engage in the desired social action.