A nurse in an outpatient clinic is caring for a client

Vital Signs
BP 124/68 mm Hg
Heart rate 80/min

Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

Which of the following statements should the nurse include in the client's teaching? Select all that apply. 

A. Start an IV bolus of lactated Ringer's solution: Not Indicated

- The client's medical record does not indicate a need for fluid resuscitation or immediate volume replacement.

B. Stay with the client for the first 15 min of the transfusion: Not Indicated

- There is no mention of a blood transfusion in the provided information. Therefore, staying with the client during a transfusion is not relevant.

C. Obtain the first unit of packed RBCs from the blood bank: Not Indicated

- There is no indication of a need for a blood transfusion in the client's assessment findings.

D. Document the blood product transfusion in the client's medical record: Not Indicated
- Since there is no indication of a blood transfusion, documenting a transfusion is not relevant.

E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: Not Indicated
- While it's important to monitor and maintain the client's blood pressure, the provided information does not suggest that the client's blood pressure is significantly low (90/60 mm Hg) or that they are receiving any infusions that need titration for blood pressure management.

Based on the information provided, the following findings require immediate follow-up:

A. Witnessing their family's death: The client witnessing their family's death during the tornado is a traumatic event that may have significant psychological implications. This finding requires immediate attention and further assessment to address the client's emotional well-being.

B. Caregiver reporting client acting differently than usual: The caregiver's concern about the client "not being themselves lately" is important and may indicate changes in the client's behavior or mental state. This requires immediate follow-up to explore the reasons behind the change in behavior.

D. Startles easily during thunderstorm: The client's heightened startle response during thunderstorms may be indicative of increased anxiety or trauma-related symptoms. This finding requires further evaluation and intervention.

G. Smoking marijuana to clear their mind: The client's use of marijuana to cope with their emotions and thoughts indicates maladaptive coping mechanisms. This finding requires immediate follow-up to address substance use and provide appropriate support.

H. Client experiences nightmares: The client's nightmares are likely related to the traumatic event they witnessed, and they may be experiencing symptoms of post-traumatic stress disorder (PTSD). This finding requires immediate attention and assessment to provide appropriate mental health support.

The other findings mentioned (C, E, F) are not concerning based on the information provided and do not require immediate follow-up. However, they may still be relevant for the client's overall assessment and care plan. The nurse should prioritize addressing the immediate mental health and emotional needs of the client, given the recent traumatic experience they went through.