A nurse is admitting a client into an inpatient mental health facility. Nurse’s Note Day 1, 0900: The client presents with a family member for possible voluntary admission for substance use disorder. The family member states that the client has been using substances for approximately 14 months. The family member is unsure what substances the client has been using. The client expressed to the family member that they would like to seek assistance with quitting. The family member reports they found the client injecting a substance approximately 1 hr ago. Client is oriented to person only. Pupils are dilated. Client appears agitated and restless. Which of the following client findings should the nurse report to the provider? (Select all that apply).

Choice A reason: Orientation to person only indicates altered mental status. This is clinically significant because it suggests impaired cognition, possibly due to acute intoxication, withdrawal, or another neurological complication. Reporting this finding is essential since orientation is a key indicator of neurological function and safety risk. Choice B reason: Dilated pupils are a physical sign consistent with stimulant use, such as cocaine or amphetamines. This finding provides objective evidence of recent substance use and may indicate acute intoxication. Reporting this is critical because it helps guide immediate medical management and monitoring for complications such as cardiovascular instability. Choice C reason: Agitation is a behavioral manifestation often seen in clients with substance use disorders, particularly during intoxication or withdrawal. While important to document, agitation alone is not as urgent to report compared to altered orientation or physiological signs like dilated pupils. It can be managed with supportive interventions and does not necessarily require immediate provider notification unless escalating to aggression or self-harm. Choice D reason: Restlessness is a common symptom associated with stimulant intoxication or withdrawal. It reflects heightened central nervous system activity and can contribute to safety risks, such as impulsivity or inability to remain calm. This finding should be reported because it provides further evidence of acute intoxication and helps the provider determine appropriate interventions.