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.
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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. A towel on the floor outside of the shower could be a tripping hazard.
B. This prevents slipping and falls, which is crucial for someone recovering from knee surgery.
C. Slippers with non-slip soles would be a safer choice to prevent falls.
D. While handrails are helpful for mobility and safety, this recommendation does not address the immediate postoperative care needs of the client following knee surgery.
Correct Answer is B
Explanation
A. Modern ICDs are designed to withstand interference from household appliances like microwaves.
B. Wearing loose clothing over the implant site can help avoid irritation and discomfort around the ICD.
C. It is recommended to keep cell phones at least six inches away from the ICD to avoid potential electromagnetic interference.
D. There is no general restriction against showering with an ICD; precautions mainly focus on the period immediately after implantation.
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