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?

Choice A rationaleImplementing 24-hr one-to-one nursing observation is a necessary precaution for a newly admitted adolescent who overdosed on prescription pain medication. This close monitoring allows for continuous assessment of the client's physical and mental status, early detection of any complications, and prevention of further self-harm attempts, especially given the prescriptions for an anxiolytic and an SSRI, which could have delayed or paradoxical effects in an overdose situation.Choice B rationaleRestricting interactions with other clients might increase the adolescent's feelings of isolation and depression, which could be counterproductive to their mental health recovery. Therapeutic interactions with peers can be beneficial.Choice C rationaleDocumenting the client's behavior every 2 hr is a standard nursing practice, but it is not sufficient for a client at high risk for self-harm following an overdose. Continuous observation provides immediate intervention capability.Choice D rationaleAdministering prescribed medication via the IM route is not necessarily a standard precaution for an overdose. The route of administration depends on the specific medication and the client's condition. Oral administration is usually preferred when the client is stable and can tolerate it.