A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?

A. Implement 24-hr one-to-one nursing observation: Following a recent overdose, the client is at high risk for self-harm or repeated suicide attempts. Continuous one-to-one observation ensures immediate intervention if the client exhibits suicidal behavior or attempts another overdose, prioritizing safety. B. Administer prescribed medication via the IM route: Changing the route of administration is not indicated solely for safety after an overdose. Medications should be given as prescribed unless the provider specifically orders a change; IM administration does not address suicide risk. C. Restrict interactions with other clients: Limiting interactions may reduce peer influence but does not directly prevent self-harm. Social isolation alone is insufficient for managing immediate suicide risk in a high-risk client. D. Document the client's behavior every 2 hr: While frequent documentation is important, two-hour intervals are inadequate for a client who has recently overdosed. Continuous observation is required to promptly identify and respond to any self-harm behavior.