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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.

Caregiver reporting client acting differently than usual

Witnessing their family's death

Attends school regularly

Client experiences nightmares

BP 122/80 mm Hg

Smoking marijuana to clear their mind

Startles easy during thunderstorm

Heart rate 99/min

Answer and Explanation

Correct Answer : A,B,D,F

A. Caregiver reporting client acting differently than usual: A change in behavior after a traumatic event can indicate a mental health concern, such as ASD, PTSD, or depression. Any significant deviation from baseline behavior in a grieving client warrants further evaluation.
B. Witnessing their family's death: Direct exposure to trauma is a significant risk factor for PTSD. Witnessing the deaths of loved ones in a natural disaster is an extreme stressor that requires psychological support and intervention.
C. Attends school regularly: The client’s ability to continue attending school and perform well academically suggests they still maintain some daily structure and function, which is a positive factor. This does not require immediate intervention.
D. Client experiences nightmares: Recurrent distressing dreams related to the traumatic event are a hallmark symptom of PTSD/ASD. Nightmares that cause significant distress or impair daily functioning should be addressed by a mental health professional.
E. BP 122/80 mm Hg: This is a normal blood pressure reading for a 16-year-old and does not require follow-up.
F. Smoking marijuana to clear their mind: Self-medicating with substances can indicate maladaptive coping mechanisms and increases the risk of substance use disorders. This requires follow-up to ensure the client receives healthier coping strategies.
G. Startles easily during thunderstorms: The client states they have always been afraid of thunderstorms, making it unclear whether this is a new trauma-related symptom or a preexisting phobia. While increased startle response can be a PTSD symptom, it does not require immediate follow-up unless it significantly impairs functioning.
H. Heart rate 99/min: While slightly elevated, this heart rate is within an acceptable range for a teenager, particularly one experiencing anxiety. It does not require urgent intervention.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Prealbumin measures nutritional status but is not related to bruising or bleeding.
B. Creatinine clearance assesses kidney function but does not directly relate to petechiae and ecchymoses.
C. Potassium levels affect cardiac and neuromuscular function, but not bruising or bleeding tendencies.
D. Petechiae and ecchymoses indicate possible thrombocytopenia (low platelet count), which can lead to excessive bruising and bleeding. A platelet count is essential to assess for clotting disorders.

A. "You can receive the immunization for influenza at any time during your pregnancy." B. "You can receive the rubella immunization during the third trimester of pregnancy." C. "The hepatitis B immunization should not be obtained until after you finish breastfeeding." D. "The immunization for varicella should be given at least 1 month prior to delivery."

Correct Answer is A

Explanation

A. Correct – The inactivated influenza vaccine is safe and recommended during any trimester to protect both the mother and baby.
B. Incorrect – The rubella vaccine (MMR) is contraindicated during pregnancy due to the risk of congenital rubella syndrome. It should be given postpartum.
C. Incorrect – The hepatitis B vaccine is safe during pregnancy and should be administered if the mother is at risk or not previously vaccinated.
D. Incorrect – The varicella vaccine is contraindicated in pregnancy due to teratogenic risks and should be given postpartum if needed.

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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.

Nursing Test Bank

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Explanation

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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.