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 precaution should the nurse take?

• A. Document the client's behavior every 2 hr.
• B. Restrict interactions with other clients.
• C. Implement 24-hr one-to-one nursing observation.
• D. Administer prescribed medication via the IM route.

Answer: (C)

Continuous, one-to-one monitoring is essential for an adolescent admitted after a prescription medication overdose because the immediate risk of self-harm or further overdose is high during acute stabilization. This level of supervision provides constant observation, allowing rapid intervention if the patient shows signs of distress, agitation, or intent, and it helps prevent access to additional medications or dangerous objects. It’s far more protective than simply documenting behavior at intervals, which can miss emergent danger. Restricting interactions with others doesn’t directly address the safety risk, and administering medications by IM route doesn’t mitigate the need for continuous supervision or the danger of further overdose. The focus here is keeping the patient safe through vigilant observation until stabilized.