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A nurse is caring for a client in a clinic.

Exhibit 1 Exhibit 2.

Nurses' Notes.

0900:

A16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths.

0910:.

Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorm, but the client admits that they have always been afraid of thunderstorms. Client admits smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They do attend school regularly and are on the honor roll.

Vital Signs.

0915:

Temperature 36.7° C (98° F).

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min.

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 follow-up.

BP 122/80 mmHg.

Heart rate 99/min.

Startles easy during thunderstorm.

Client experiences nightmares.

Witnessing their family’s death.

Caregiver reporting client acting differently than usual.

Attends school regularly.

Smoking marijuana to clear their mind.

Answer and Explanation

Correct Answer : B,D,E,H

• B: Heart rate 99/min. This is a finding that requires immediate follow-up because it is above the normal range for a 16-year-old client, which is 60 to 100 beats per minute. A high heart rate could indicate anxiety, stress, pain, infection or other conditions that need to be addressed.

• D: Client experiences nightmares. This is a finding that requires immediate follow-up because it could indicate post-traumatic stress disorder (PTSD), which is a mental health condition that can develop after witnessing or experiencing a traumatic event. PTSD can cause distressing symptoms such as nightmares, flashbacks, intrusive thoughts, avoidance, negative mood and hyperarousal. PTSD can interfere with the client’s daily functioning and well-being and requires professional treatment.

• E: Witnessing their family’s death. This is a finding that requires immediate follow-up because it is the most likely cause of the client’s PTSD symptoms and emotional distress. Witnessing the death of one’s family members is a devastating and traumatic experience that can have lasting effects on the client’s mental health. The client may benefit from grief counseling, trauma-focused therapy, medication or other interventions to help them cope with their loss and trauma.

• H: Smoking marijuana to clear their mind. This is a finding that requires immediate follow-up because it indicates that the client is using an illicit substance to self-medicate their emotional pain. Smoking marijuana can have negative effects on the client’s physical and mental health, such as impairing their memory, cognition, judgment, coordination and motivation. It can also increase the risk of addiction, dependence and withdrawal symptoms. The client may need substance abuse counseling, education, referral or other services to help them quit smoking marijuana and find healthier ways to cope with their feelings.
The other findings do not require immediate follow-up for the following reasons:

• A: BP 122/80 mmHg. This is not a finding that requires immediate follow-up because it is within the normal range for a 16-year-old client, which is 110 to 120/70 to 80 mmHg. A normal blood pressure indicates that the client’s cardiovascular system is functioning well and there are no signs of hypertension or hypotension.

• C: Startles easy during thunderstorm. This is not a finding that requires immediate follow-up because it is a normal reaction to a loud noise or a frightening stimulus. The client admits that they have always been afraid of thunderstorms, which suggests that this is not a new or unusual behavior for them. However, the nurse may want to monitor the client’s anxiety level and provide reassurance and comfort during thunderstorms.

• F: Caregiver reporting client acting differently than usual. This is not a finding that requires immediate follow-up because it is a vague and subjective statement that does not specify how the client is acting differently or what changes have occurred in their behavior. The nurse may want to ask the caregiver for more details and examples of how the client has changed since the traumatic event and assess whether these changes are normal or concerning.

• G: Attends school regularly. This is not a finding that requires immediate follow-up because it indicates that the client is maintaining their academic performance and social interactions despite their trauma and grief. Attending school regularly can provide the client with a sense of routine, structure, support and achievement that can help them cope with their situation. However, the nurse may want to check with the client’s teachers and peers to see if they have noticed any changes in the client’s mood, behavior or participation at school.

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Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choiceb. Instruct the client to notify the provider if diarrhea develops.

Choice A rationale:

Infusing penicillin G over 10 minutes is not recommended as it may cause adverse reactions.The infusion rate should be based on the specific guidelines for the medication and patient condition.

Choice B rationale:

Diarrhea can be a sign of a serious side effect called Clostridium difficile-associated diarrhea, which can occur with antibiotic use.It is important for the client to notify the provider if this symptom develops.

Choice C rationale:

Penicillin G should be stored according to the manufacturer’s instructions, which typically do not include refrigeration after reconstitution.Incorrect storage can affect the medication’s efficacy.

Choice D rationale:

Checking for a sulfa allergy is not relevant for penicillin G administration.Sulfa allergies are related to sulfonamide antibiotics, not penicillins.

A. “Have you taken your medication today?”. B. “How long have you been hearing the voices?”. C. “What are the voices telling you?”. D. “I realize the voices are real to you, but I don’t hear anything.”. E. undefined

Correct Answer is C

Explanation

The correct answer is choice C. The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.

The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental (choice A).

The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time (choice B).

The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation (choice D).

The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?

Correct Answer is C

Explanation

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