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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.

Client experiences nightmares

Heart rate 99/min

Attends school regularly

Smoking marijuana to clear their mind

Startles easy during thunderstorm Witnessing their family's death

BP 122/80 mm Hg

Caregiver reporting client acting differently than usual

Answer and Explanation

Correct Answer : A,D,E,G

A.   The client's nightmares could be indicative of post-traumatic stress disorder (PTSD), especially after the client’s parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago.
B.   A heart rate of 99/min is within the normal range for the client’s age and requires no need for follow-up.
C.   While regular attendance at school is generally considered a positive behavior, it does not directly indicate a need for immediate follow-up. However, it is relevant information for assessing the client's overall functioning and resilience in the context of their recent traumatic experience.
D.   The client's use of marijuana as a coping mechanism raises concerns about their mental health and potential substance abuse. Immediate follow-up is needed to address this issue and provide appropriate support and intervention.
E.   Startles easily during thunderstorms and witnessing their family's death are findings that indicate symptoms of post-traumatic stress disorder (PTSD) or acute stress reaction following the traumatic event of witnessing their family's death. Immediate follow-up is

necessary to assess the client's mental health status and provide appropriate support and counseling.
F.   A blood pressure of 122/80 mm Hg falls within the normal range for adolescents and does not indicate an immediate medical concern. While blood pressure monitoring is important for overall health assessment, this finding alone does not warrant immediate follow-up in the context of the client's presenting issues.
G.   The caregiver's observation that the client is acting differently than usual suggests a change in behavior or mental health status that requires further assessment and intervention. Immediate follow-up is needed to explore the caregiver's concerns and address any underlying issues affecting the client's well-being

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Correct Answer is B

Explanation

A. While revising the current policy for catheter care may be necessary, it is not the first step in addressing the increase in infections. Understanding the factors contributing to the infections is crucial before policy revision.
B. Identifying possible precipitating factors related to the infections is the first step in addressing the issue. This involves investigating the circumstances surrounding the infections to determine potential causes and contributing factors.
C. While staff training is important, scheduling training before understanding the root cause of the infections may not effectively address the problem.
D. Meeting with providers to discuss measures to decrease infections may be necessary, but it should occur after identifying the precipitating factors to ensure targeted and effective interventions.

A. Position the client over an overbed table prior to the procedure. B. Instruct the client to empty her bladder prior to the procedure. C. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. D. Initiate NPO status 4 hr prior to the procedure.

Correct Answer is B

Explanation

A. Positioning the client over an overbed table is not appropriate for a paracentesis procedure and may interfere with the procedure.
B. Emptying the bladder before the procedure helps to reduce the risk of accidental bladder puncture during paracentesis.
C. Administering IV fluids prior to the procedure is not typically indicated for a paracentesis, unless specifically ordered by the provider for hydration purposes.
D. NPO status is not typically required before a paracentesis procedure unless otherwise specified by the provider.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a client at a clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdown due to dropdown.

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.