A nurse is developing a plan of care for a school-age child who has ADHD. Which of the following interventions should the nurse include in the plan?

A. Venlafaxine and frequent yawning/weight loss: Frequent yawning and weight loss are not typical signs of an adverse reaction to venlafaxine. These symptoms can occur with various conditions, but they do not necessarily require withholding the medication.
B. Olanzapine and frequent urination: Frequent urination is not a known side effect of olanzapine. However, the nurse should assess the client for other factors contributing to this symptom. It may not be severe enough to require withholding the medication without further evaluation.
C. Fluoxetine and muscle rigidity/tachycardia: Muscle rigidity and tachycardia could indicate serotonin syndrome, a potentially life-threatening condition. This requires immediate intervention, and the medication should be withheld while notifying the provider for further evaluation and treatment.
D. Nortriptyline and nausea/dry mouth: Nausea and dry mouth are common side effects of tricyclic antidepressants like nortriptyline. These symptoms typically do not require withholding the medication, but the nurse should monitor the client for any worsening or additional adverse effects.

Rationale for correct choices:

• Cognition: The client’s cognition is intact, indicating that alcohol withdrawal symptoms have resolved and the client is no longer experiencing significant cognitive impairment. This reflects positive progress in recovery and stabilization.
• Client resolves to limit alcohol consumption: The client expresses a desire to limit alcohol consumption and has expressed fear of using alcohol again. This willingness to take responsibility for their recovery indicates progress toward healthier coping mechanisms.
• Movement through the stages of grief: The client is showing progress in working through their grief, transitioning from guilt to sadness. This indicates emotional processing and movement through the stages of grief, which is important for healing and recovery.
• Participation in group therapy: The client is attending group therapy twice daily and participating in conversations. Active participation in therapy shows engagement with the recovery process and willingness to work through their issues with support.

Rationale for incorrect choices:

• Appetite: There is no information provided in the notes or vital signs about the client's appetite. While appetite may improve over time, it is not explicitly mentioned here, and the focus should be on more direct recovery indicators.
• Vital signs: While the vital signs have stabilized since admission, these factors are more indicative of physical recovery rather than progress in the treatment plan. The other findings are stronger indicators of the client’s emotional and psychological progress in recovery.