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A nurse is assisting with the care of client in a clinic.

Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.

Witnessing the death of their parents and sibling

Attends school regularly

Client experiences nightmares

Blood pressure 122/80 mm Hg

Heart rate 99/min

Startles easy during thunderstorm

Friend reporting client is not themselves

Smoking marijuana to clear their mind

Answer and Explanation

Correct Answer : A,C,G,H

A. Witnessing the death of their parents and sibling: Experiencing such severe trauma places the client at high risk for post-traumatic stress disorder (PTSD) and complicated grief. Immediate follow-up is necessary to assess emotional safety and provide appropriate mental health interventions.

B. Attends school regularly: Regular school attendance is a positive sign of functioning and does not require immediate follow-up. It indicates that the client maintains some level of daily routine and social engagement.

C. Client experiences nightmares: Nightmares following trauma can indicate PTSD or acute stress reaction. These symptoms warrant prompt assessment and intervention to prevent worsening sleep disturbances, anxiety, or functional impairment.

D. Blood pressure 122/80 mm Hg: This is within normal limits for a 16-year-old and does not require immediate follow-up. It is not indicative of acute physical risk.

E. Heart rate 99/min: While slightly elevated, this heart rate is within a mild range of normal for adolescents under stress and does not require immediate follow-up unless accompanied by other acute symptoms.

F. Startles easily during thunderstorms: A mild startle response, especially with a prior fear of storms, is not an urgent concern. While it may relate to trauma, it is not immediately dangerous or requiring urgent follow-up.

G. Friend reporting client is not themselves: Changes in behavior observed by peers can indicate worsening mental health or risk of self-harm. Immediate follow-up is important to evaluate mood, coping, and safety.

H. Smoking marijuana to clear their mind: Self-medicating with substances is a significant safety concern, particularly in adolescents coping with trauma. Immediate follow-up is required to assess for substance use disorder and potential harm to mental and physical health.

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Correct Answer is C

Explanation

A. Leukemia: Leukemia primarily affects white blood cell production and bone marrow function. While it can cause anemia, low iron and vitamin B levels are more directly related to nutritional deficiencies rather than a primary hematologic malignancy.

B. Hepatitis: Hepatitis involves inflammation of the liver and may affect liver function tests, bilirubin, and clotting factors. It does not typically cause concurrent deficiencies in iron and vitamin B unless chronic malnutrition or malabsorption is present.

C. Anemia: Low iron and vitamin B (particularly B12 or folate) directly impair red blood cell production, leading to various types of anemia, such as iron-deficiency anemia or megaloblastic anemia. Monitoring for pallor, fatigue, and laboratory indicators of anemia is essential for appropriate management.

D. Steatotic liver disease: Fatty liver disease affects hepatocytes and liver metabolism but is not typically associated with primary deficiencies in iron and vitamin B. Nutritional deficiencies may coexist but are not the direct cause of laboratory abnormalities in this context.

A. Attach a blood pressure cuff to the client's upper arm B. Tell the client to expect a mild stinging sensation during the test. C. Assist the client to the orthopneic position. D. Instruct the client to remain as still as possible during the recording

Correct Answer is D

Explanation

A. Attach a blood pressure cuff to the client's upper arm: A blood pressure cuff is not required for obtaining a 12-lead ECG. Its use does not contribute to the quality of the ECG tracing and is unnecessary during this procedure.

B. Tell the client to expect a mild stinging sensation during the test: A 12-lead ECG is noninvasive and painless. Electrodes are placed on the skin with adhesive gel or pads, and clients typically feel no stinging. Providing accurate expectations helps reduce anxiety.

C. Assist the client to the orthopneic position: The orthopneic position is used to ease breathing in clients with respiratory distress. For a 12-lead ECG, the client should lie supine to ensure proper electrode placement and accurate readings.

D. Instruct the client to remain as still as possible during the recording: Movement can create artifacts on the ECG tracing, making interpretation difficult. Remaining still ensures accurate detection of cardiac electrical activity and reliable diagnostic results.

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A nurse is assisting with the care of client in a clinic. Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.

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A nurse is assisting with the care of client in a clinic.

Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.