A nurse is assisting in the admission of a 30-year-old client to an inpatient mental health facility.

Exhibits

For each finding, click to specify if the finding is consistent with opioid, stimulant, or hallucinogen intoxication. Each finding may be consistent with more than 1 substance or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Choice A rationale: Pupils

Dilated pupils are a common sign of stimulant intoxication, particularly with substances like methamphetamine. Given that the client recently injected an unknown substance, pupil dilation could indicate acute intoxication and require urgent evaluation to prevent potential overdose or complications.

Choice B rationale: Heart rate

A heart rate of 121–124/min is significantly elevated, suggesting tachycardia, which can be related to stimulant use (such as methamphetamine) or withdrawal effects. High heart rates, especially in the context of withdrawal, can increase the risk of arrhythmias or cardiac complications, requiring close monitoring and intervention.

Choice C rationale: Orientation

The client was oriented only to person upon admission, which suggests altered mental status. Substance intoxication or withdrawal can impair cognitive function, decision-making, and awareness, increasing the risk for agitation, confusion, or more severe withdrawal symptoms such as hallucinations or seizures.

Choice D rationale: Respiratory rate

A respiratory rate of 20/min falls within the normal range (typically 12–20 breaths per minute) and does not indicate immediate distress requiring escalation of care.

Choice E rationale: Medical history

While knowing the client’s medical history is important for long-term care planning, it does not require immediate reporting unless the client has a history of conditions that could complicate withdrawal.

Choice F rationale: Oxygen saturation

An oxygen saturation of 98% on room air is within normal limits, meaning oxygenation is adequate. There is no immediate concern requiring intervention based on this finding.

Choice A rationale

Asking a client with paranoid personality disorder why they are suspicious can be perceived as confrontational and challenging. Individuals with this disorder have a pervasive distrust of others, and directly questioning their suspicions is likely to increase their defensiveness and further impair the therapeutic relationship. A more indirect and gradual approach is necessary to build trust.

Choice B rationale

Using an overly friendly approach can be misinterpreted by a client with paranoid personality disorder. Their inherent distrust may lead them to suspect ulterior motives behind such excessive friendliness, making them more suspicious and resistant to forming a therapeutic alliance. A neutral and professional demeanor is more likely to be perceived as safe and trustworthy.

Choice C rationale

Being vague when answering a client's questions about instructions can exacerbate the mistrust inherent in paranoid personality disorder. Clear, consistent, and direct communication is essential to build trust and reduce suspicion. Vagueness can be interpreted as dishonesty or an attempt to deceive, further damaging the therapeutic relationship.

Choice D rationale

Demonstrating a neutral demeanor is the most appropriate strategy when beginning a therapeutic relationship with a client who has paranoid personality disorder. A neutral approach avoids appearing overly friendly or confrontational, allowing the client to feel safer and less threatened. This helps to establish a sense of predictability and trustworthiness, which is crucial for building rapport with individuals who are inherently suspicious of others' intentions.