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A nurse is caring for a client in a clinic.

Vital Signs 0915:

Temperature 36.7° C (98° F)

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min

Nurses' Notes 0900:

A 16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivors and witnessed their family's deaths.

0910:

The client appears anxious but answers appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorms, but the client admits that they have always been afraid of thunderstorms. The client admits to smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They attend school regularly and are on the honor roll.

Based on the information in the client's medical record, which of the following findings requires immediate follow-up?

Select the 4 findings that require follow-up.

Attends school regularly

Caregiver reporting client acting differently than usual

Witnessing their family's death

Heart rate 99/min

Smoking marijuana to clear their mind

Client experiences nightmares

Startles easy during thunderstorm

Answer and Explanation

Correct Answer : B,C,E,F

A.   Attends school regularly: While attending school regularly is important, it is not an immediate concern that requires follow-up compared to the other more pressing issues related to the traumatic event and the client's mental well-being.
B.   Caregiver reporting client acting differently than usual: This finding requires immediate follow-up because it indicates a change in the client's behavior and could be indicative of emotional distress or mental health issues, especially considering the recent traumatic event they experienced.

C.   Witnessing their family's death: Witnessing the death of family members in a traumatic event like a tornado is a significant and potentially traumatizing experience that requires immediate follow-up and support.
D.   Heart rate 99/min: While a heart rate of 99/min is slightly elevated, it is not a critical finding that requires immediate follow-up in this context. The other findings are more relevant to the client's psychological well-being.
E.   Smoking marijuana to clear their mind: The client's use of marijuana to cope with their thoughts and feelings should be addressed promptly, as it could indicate maladaptive coping mechanisms or potential substance abuse.
F.   Client experiences nightmares: Experiencing nightmares could be a symptom of post-traumatic stress disorder (PTSD) or other mental health concerns related to the traumatic event.
G.   BP 122/80 mm Hg: A blood pressure of 122/80 mm Hg is within a normal range and is not a cause for immediate concern.
H.   Startles easy during thunderstorm: While startle responses can be related to anxiety, this specific finding is not as pressing as the client's reported coping mechanisms and traumatic experiences.

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Correct Answer is D

Explanation

A. Opioid medications can cause constipation, and increasing fluid intake helps prevent dehydration and promotes bowel regularity. However, it does not directly prevent cosntipation.

B. Incorrect. While some laxatives or stool softeners might be recommended, mineral oil is generally not recommended due to its potential to interfere with the absorption of fat-soluble vitamins.

C. Incorrect. Increasing insoluble fiber intake, rather than decreasing it, can help prevent constipation.

D. Increasing exercise is key in preventing constipation caused by opiod analgesics

A. Current medications B. Temperature C. Hemoglobin and hematocrit D. WBC count E. Blood pressure F. Respiratory rate G. Stool results H. Heart rate

Correct Answer is ["A","C","E","G","H"]

Explanation

The correct answer is:Choices c, e, g, h, and a.

Choice A rationale (Current medications): The client is taking Ibuprofen 800 mg three times daily as needed for arthritis pain.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation, ulcers, and bleeding, especially when used at high doses or for a prolonged period 1 2. Given the client’s symptoms of abdominal pain and a history of dark, tarry stool, the medication could be contributing to these symptoms and warrants further investigation.

Choice B rationale (Temperature): The client’s temperature is 37.5° C (99.5° F), which is within the normal range 3 4. Therefore, it does not require immediate follow-up.

Choice C rationale (Hemoglobin and hematocrit): The client’s hemoglobin level is 9.1 g/dL, which is lower than the normal range of about 13.0 to 17.5 g/dL for adult males and 12.0 to 15.5 g/dL for adult females 5 6.The client’s hematocrit is 27%, which is also lower than the normal range of about 38.3% to 48.6% for adult males and 35.5% to 44.9% for adult females 7.Low hemoglobin and hematocrit levels can indicate anemia, which could explain the client’s reported fatigue and pale mucous membranes 8 7.

Choice D rationale (WBC count): The client’s WBC count is 6,700/mm3, which falls within the normal range of about 4,500 to 11,000 WBCs per microliter 9 10. Therefore, it does not require immediate follow-up.

Choice E rationale (Blood pressure): The client’s blood pressure is 90/50 mm Hg, which is lower than the normal range 11. Low blood pressure can cause symptoms such as dizziness, fainting, or blurred vision and requires immediate follow-up.

Choice F rationale (Respiratory rate): The client’s respiratory rate is 18 breaths per minute, which is within the normal range for adults of about 12 to 20 breaths per minute 4 12. Therefore, it does not require immediate follow-up.

Choice G rationale (Stool results): The client’s stool tested positive for blood (Hemoccult positive), which could indicate gastrointestinal bleeding 13. This finding, combined with the client’s reported abdominal pain and history of dark, tarry stool, requires immediate follow-up.

Choice H rationale (Heart rate): The client’s heart rate is 118 beats per minute, which is higher than the normal range for adults of about 60 to 100 beats per minute 14.A high heart rate, or tachycardia, can be caused by factors such as stress, anxiety, physical exertion, dehydration, and certain medical conditions 14. Given the client’s reported symptoms and medical history, this finding warrants immediate follow-up.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["A","C","E","G","H"]

Explanation

A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings that requires follow-up care.

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client in the medical-surgical unit. Exhibits Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?