A nurse is collecting data from an adolescent client who has a conduct disorder.
Which of the following findings is the nurse's priority?

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

Being married is generally considered a protective factor against depression due to increased social support and companionship. Research often indicates that individuals in stable marital relationships tend to have lower rates of depression compared to unmarried individuals.

Choice B rationale

Chronic illness is a significant risk factor for depression. The ongoing physical discomfort, limitations in daily activities, and psychological burden associated with chronic conditions can increase vulnerability to mood disorders. The physiological and emotional impact of managing a long-term illness contributes to this increased risk.

Choice C rationale

Alcohol use disorder is strongly associated with an increased risk of depression. Alcohol is a central nervous system depressant that can disrupt neurotransmitter balance in the brain, leading to or exacerbating depressive symptoms. Furthermore, the social and personal consequences of alcohol abuse can contribute to feelings of isolation and despair.

Choice D rationale

Early childhood trauma is a well-established risk factor for developing depression later in life. Adverse experiences during childhood can have long-lasting effects on brain development, stress response systems, and emotional regulation, increasing susceptibility to mental health disorders, including depression.

Choice E rationale

Middle-class economic status is not typically identified as a specific risk factor for depression. While socioeconomic factors can influence mental health, depression can affect individuals across all economic strata. Poverty and financial instability are more commonly associated with increased risk.