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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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Wear cotton underwear: Cotton underwear allows better air circulation and reduces moisture accumulation, which helps prevent bacterial growth in the genital area. Proper underwear choice is a simple preventive measure that supports urinary tract health.

B. Drink orange juice daily for 3 to 4 weeks: While vitamin C may help acidify urine slightly, there is no evidence supporting long-term consumption specifically for UTI prevention. Excessive intake can also irritate the bladder or cause gastrointestinal upset.

C. Take the prescribed antibiotic until manifestations are gone: Antibiotics should be taken for the full prescribed course, not just until symptoms resolve. Stopping early can lead to incomplete eradication of bacteria and increase the risk of resistance.

D. Restrict fluid intake to 1 L per day: Restricting fluids can worsen UTIs by reducing urine output, which limits bacterial flushing from the urinary tract. Adequate hydration is recommended to help prevent and manage UTIs.

A. "We will wrap our baby in a blanket under the car seat straps when it is cold out." B. "We will make sure to activate the air bag when we place the car seat in the front passenger seat." C. "We will switch our baby's car seat to forward facing when they turn one." D. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out."

Correct Answer is D

Explanation

A. "We will wrap our baby in a blanket under the car seat straps when it is cold out.": Placing a blanket under the straps can prevent proper restraint and reduce the effectiveness of the harness, increasing the risk of injury during a crash. Blankets should go over the secured straps instead.

B. "We will make sure to activate the air bag when we place the car seat in the front passenger seat.": Airbags can cause serious injury or death to infants in the event of a collision. Infants should always ride in the back seat, away from active airbags.

C. "We will switch our baby's car seat to forward facing when they turn one.": Current safety guidelines recommend keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight allowed by the car seat manufacturer.

D. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out.": Checking the car seat’s surface temperature helps prevent burns from hot straps or seat material. This demonstrates understanding of infant safety measures during car seat use.

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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.