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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Measure the client's abdominal girth daily: Monitoring abdominal girth helps assess the progression or reduction of ascites and guides the effectiveness of interventions such as diuretic therapy or paracentesis. Daily measurements provide objective data for evaluating fluid accumulation.
B. Position the client supine with legs elevated: Elevating the legs while supine is more appropriate for peripheral edema, not ascites. For ascites, semi-Fowler’s or upright positioning is preferred to promote comfort and reduce pressure on the diaphragm.
C. Restrict the client's sodium intake to 3 g per day: Sodium restriction is typically recommended to manage fluid retention in ascites, but standard guidelines suggest limiting sodium to 2 g per day, not 3 g, to optimize effectiveness.
D. Keep the client's daily protein intake below 0.8 g/kg: Clients with cirrhosis and ascites often require adequate protein to prevent muscle wasting and malnutrition. Restricting protein excessively can worsen nutritional status and is generally not recommended unless the client has hepatic encephalopathy.
Correct Answer is B
Explanation
A. Reduced anxiety: While anxiety may improve with overall health stabilization, it is not a direct indicator of potassium replacement effectiveness. Potassium primarily affects neuromuscular and cardiac function rather than emotional state.
B. Normal sinus rhythm: Hypokalemia can cause cardiac arrhythmias. The presence of a normal sinus rhythm indicates that potassium levels have been corrected and the heart’s electrical activity is stabilized, reflecting a positive response to supplementation.
C. Decreased urinary output: Changes in urinary output are not a direct measure of potassium replacement effectiveness and may indicate other complications, such as renal impairment or fluid imbalance.
D. Decreased blood pressure: Blood pressure changes are not a direct outcome of potassium supplementation and could suggest unrelated cardiovascular issues. Normalization of cardiac rhythm is a more specific indicator of intervention success.
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