A nurse is caring for a 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 follow-up.
Smoking marijuana to clear their mind
BP 122/80 mm Hg
Witnessing their family's death
Attends school regularly
Client experiences nightmares
Startles easy during thunderstorm
Heart rate 99/min
Caregiver reporting client acting differently than usual
Correct Answer : A,C,E,F,H
A. Smoking marijuana to clear their mind
Using marijuana to cope with emotional pain or trauma is concerning. It suggests that the client may be turning to substances to manage their stress, anxiety, or trauma-related symptoms, which could lead to substance use disorder. It is important to address the substance use as it may hinder the healing process, especially given the trauma the client has experienced.
B. BP 122/80 mm Hg
This blood pressure reading is within the normal range for a 16-year-old. A blood pressure of 120/80 mm Hg or lower is generally considered normal for adolescents, so there is no immediate need for follow-up regarding this finding. This vital sign does not indicate an urgent issue.
C. Witnessing their family's death
Witnessing the violent deaths of close family members is a major traumatic event that can lead to post- traumatic stress disorder (PTSD), complicated grief, or other mental health issues. This experience is significant and requires immediate follow-up to assess how the client is processing the trauma and to ensure they are receiving appropriate mental health support, such as therapy or counseling.
D. Attends school regularly
While it's important to monitor the client’s social and academic functioning, attending school regularly is a positive indicator. The client is able to continue their education despite their trauma, which is a sign of resilience. However, this finding does not require immediate follow-up, but ongoing assessment may be needed to evaluate if there are any underlying issues affecting their school performance or social interactions.
E. Client experiences nightmares
Nightmares, particularly those related to a traumatic event, are a common symptom of post-traumatic stress disorder (PTSD). Since the client witnessed the traumatic deaths of their family members, this could be part of a larger pattern of distress. Follow-up is needed to evaluate the severity of the nightmares and determine whether the client needs trauma-focused therapy or other interventions to address potential PTSD symptoms.
F. Startles easily during thunderstorms
This is a common symptom of hypervigilance, which is associated with PTSD or acute stress disorder (ASD) following trauma. The client’s startle response, particularly in response to thunderstorms (which could be a trigger), warrants immediate follow-up. The nurse should assess the client's emotional response to stimuli and provide guidance on managing triggers, as well as explore whether the client needs therapy or trauma-informed care.
G. Heart rate 99/min
A heart rate of 99 beats per minute is within the normal range for adolescents and is not concerning on its own. While anxiety or stress could cause a mild increase in heart rate, this finding does not require immediate intervention unless there are other signs of distress, such as chest pain or difficulty breathing.
H. Caregiver reporting client acting differently than usual
A change in behavior, as reported by the caregiver, is concerning. It may indicate that the client is struggling emotionally or mentally, particularly after experiencing such a traumatic loss. This behavior could be linked to depression, anxiety, or trauma-related symptoms, and therefore requires immediate follow-up to assess the client's mental health and ensure that they are receiving appropriate support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Client rates lower back pain as 0 on a scale from 0 to 10:
On Day 1, the client reported lower back pain, which could be associated with uterine contractions or other complications. By Day 2, the pain has resolved completely, with the client reporting a pain level of 0/10. This is a clear sign of improvement in her condition, especially since pain is often a key indicator of progress in antepartum care.
No reports of vaginal discharge:
On Day 1, the client reported pinkish vaginal discharge, which can be indicative of preterm labor or other complications. By Day 2, the absence of vaginal discharge suggests that the situation has improved, and the risk of preterm labor may be decreasing.
No uterine contractions noted:
On Day 1, the client had uterine contractions occurring every 8 minutes, which could be indicative of early labor or preterm labor. By Day 2, the absence of uterine contractions is a positive sign that the client is no longer experiencing early labor signs. This indicates that the situation is improving.
No further reports of burning with urination:
On Day 1, the client reported burning with urination, which was indicative of a urinary tract infection (UTI). On Day 2, the client no longer reports this symptom, suggesting that the urinary symptoms have resolved, and the infection may be improving, especially in light of ongoing treatment (e.g., antibiotics).
Laboratory Results Indicating Improvement:
WBC count 12,000/mm³ (Day 2) vs. 16,000/mm³ (Day 1):
The WBC count has decreased from 16,000/mm³ on Day 1 (which indicated infection or inflammation) to 12,000/mm³ on Day 2. Although the WBC count is still slightly elevated above the normal range (5,000-10,000/mm³), the decrease in WBC count suggests that the client's body is responding to treatment, and the infection or inflammation may be resolving.
Vital Signs Indicating Improvement:
Temperature 37.1° C (98.7°F) (Day 2) vs. 38.4° C (101.1°F) (Day 1):
The client’s fever has resolved, with a temperature decrease from 38.4°C (101.1°F) on Day 1 to 37.1°C (98.7°F) on Day 2. Fever is a common sign of infection, and the reduction in temperature suggests that the infection (likely a urinary tract infection) is being controlled and is improving.
Correct Answer is B
Explanation
A. This response avoids addressing the client’s interest in alternative therapies and does not provide the
necessary guidance.
B. It is essential to provide information on safe alternative therapies and help the client identify qualified practitioners who offer these services.
C. Relying solely on online support groups may lead to unproven or unsafe treatments.
D. Encouraging the client to try any therapy without considering safety or evidence-based practices could be harmful.
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