Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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

Rationale:

Step 1: Administer Oxygen at 2L/min via Nasal Cannula

The client's oxygen saturation has dropped from 97% to 92% on room air, which indicates potential myocardial oxygen demand exceeding supply. Oxygen therapy helps improve myocardial oxygenation, which is crucial for clients with suspected acute coronary syndrome (ACS).

Step 2: Administer Sublingual Nitroglycerin

The client’s chest pain has worsened (increased from 4/10 to 7/10) and is associated with shortness of breath, which suggests possible myocardial ischemia. Nitroglycerin causes vasodilation, reducing myocardial oxygen demand and improving coronary perfusion.

It is a first-line treatment for suspected angina or acute coronary syndrome (ACS).

Incorrect Options

Step 1:

Prepare the client for cardiac catheterization: While a catheterization may be necessary, immediate interventions (oxygen, nitroglycerin) take priority before an invasive procedure.

Request a prescription for an increase in statin medication: Adjusting statins is a long-term strategy; it does not address the acute issue of chest pain and shortness of breath.

Step 2:

Request a prescription for a beta-blocker: Beta-blockers reduce heart rate and myocardial oxygen demand, but nitroglycerin provides more immediate relief for chest pain.

Check a STAT cardiac troponin: A repeat troponin may be necessary, but the initial focus is on stabilizing the client’s oxygenation and relieving chest pain.

A. The nurse should break the neck of the ampule toward their body. B. The nurse should dispose of the ampule in the trash can. C. The nurse should use a filter needle to withdraw the medication. D. The nurse should use the same needle to draw up and inject the client.

Correct Answer is C

Explanation

A. The nurse should break the ampule away from the body to avoid injury.
B. The ampule should be disposed of in a sharps container, not in the trash.
C. A filter needle prevents glass particles from entering the syringe, reducing the risk of embolism or irritation.
D. A new needle should be used for injection to prevent glass contamination.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Complete the following sentence by using the list of options. After notifying the provider, the nurse should first administer dropdownand thendropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?

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.