A nurse is assisting with the care of a client.

Which of the following findings requires further action by the nurse? Select all that apply.

Adolescent clients exposed to severe trauma are at high risk for developing acute stress disorder or post-traumatic stress disorder (PTSD). Following a catastrophic event such as a natural disaster with loss of immediate family, nurses must closely monitor for psychological, behavioral, and coping-related changes. Warning signs include re-experiencing trauma, avoidance behaviors, substance use, and changes in emotional regulation. Early identification of high-risk findings is essential to prevent worsening mental health outcomes and ensure timely intervention.

Rationale:

A. Attends school regularly is a positive protective factor and indicates preserved daily functioning. Despite significant trauma exposure, maintaining academic performance suggests some level of resilience and structured routine. This finding does not require immediate follow-up as it reflects stability rather than deterioration.

B. Friend reporting the client is not themselves requires immediate follow-up because it indicates observable behavioral change from baseline functioning. Collateral information suggests possible emotional dysregulation, withdrawal, or early psychiatric symptoms. This subjective report from a close observer is an important indicator of psychological distress requiring further assessment.

C. Heart rate 99/min is within the upper normal range for adolescents and may be related to anxiety or situational stress. It does not indicate acute medical instability requiring urgent intervention. This physiological finding is not prioritized compared to significant psychological risk factors in this case.

D. Blood pressure 122/80 mmHg is within normal limits for a 16-year-old client and does not indicate hemodynamic instability. There are no signs of hypertensive crisis or hypotension. This finding is not clinically concerning in the context of the current presentation.

E. Witnessing the death of parents and sibling is a major traumatic event that places the client at extremely high risk for PTSD, depression, and complicated grief. This level of trauma exposure is a key predictor of long-term psychological impairment. It requires immediate follow-up for mental health evaluation and support services.

F. Smoking marijuana to clear the mind is a maladaptive coping mechanism indicating substance use as emotional regulation. This behavior increases risk for dependency, worsened mental health symptoms, and impaired adolescent brain development. It requires immediate intervention and psychosocial support.

G. Experiencing nightmares is a core re-experiencing symptom of trauma-related disorders such as PTSD. Nightmares indicate ongoing psychological distress and failure to process traumatic memories. This symptom requires immediate follow-up for trauma-focused mental health assessment.

H. Startling easily during thunderstorms may be an exaggerated startle response. However, the client also reports long-standing fear of thunderstorms. Although this may be a symptom of hyperarousal, it is less urgent compared to trauma exposure, substance use, and re-experiencing symptoms that indicate significant psychological deterioration.

Therapeutic communication is essential when caring for clients coping with a terminal diagnosis. Nurses should provide emotional support by acknowledging feelings, offering presence, and allowing the client to express fear, sadness, or uncertainty without judgment. Responses should focus on empathy and support rather than false reassurance or premature problem-solving. Presence and active listening help build trust and promote emotional comfort during difficult moments.

Rationale:
A. “I will stay with you until you're feeling better.” This is therapeutic because it offers presence, emotional support, and reassurance without dismissing the client’s feelings. Remaining with a distressed client demonstrates empathy and allows them space to process emotions safely. This response promotes trust and helps reduce feelings of isolation during a vulnerable time.

B. “Do you want me to tell you about hospice care?” This introduces education too early when the client is actively upset and tearful. Immediate emotional support should come before discussing care planning or future services. Although hospice education may be appropriate later, the priority at this moment is addressing emotional distress.

C. “I'm going to contact your caregivers so they can be here with you.” This assumes the client wants others involved and removes autonomy from the decision-making process. The nurse should first ask permission before contacting family or caregivers. Immediate emotional support should focus on the client’s expressed feelings rather than making assumptions about their preferences.

D. “Everything will be just fine. You'll see.” This is an example of false reassurance and is not therapeutic. It minimizes the seriousness of the diagnosis and may make the client feel misunderstood or dismissed. Honest, supportive communication is more effective than offering unrealistic promises about the outcome.