A nurse is caring for a client in a clinic.

Exhibits

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.

After notifying the provider, the nurse should first administer oxygen at 2 L/min via nasal cannula and then administer sublingual nitroglycerin

Rationale

Administer oxygen at 2 L/min via nasal cannula

The client is experiencing shortness of breath and chest pain with a decrease in oxygen saturation (92%), which is a concern, indicating that the client may be experiencing an acute cardiovascular event such as a myocardial infarction (MI). Administering oxygen helps to increase the oxygen supply to the heart and other vital organs.

Administer sublingual nitroglycerin

Nitroglycerin is a vasodilator that can help relieve chest pain associated with conditions like angina or myocardial infarction by increasing blood flow to the heart and reducing myocardial oxygen demand. The client’s pain level has increased to 7/10 on the pain scale, which suggests the chest pain may be related to an acute cardiac event.

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.