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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. Incorrect. Unused medication replacement might not be necessary every 6 months and depends on the expiration date of the medication container.

B. Incorrect. Dabigatran capsules should not be crushed or opened, as it can affect the medication's efficacy and increase the risk of bleeding.

C. Incorrect. Storing the medication in the refrigerator is not necessary for dabigatran.

D. Correct. Keeping the medication in the original container helps protect it from moisture and ensures proper identification and labeling.

A. Document the client's level of understanding about potential adverse effects. B. Teach the client how to insert the diaphragm. C. Determine the client's knowledge about diaphragm use. D. Supervise return demonstration of diaphragm use.

Correct Answer is C

Explanation

A. Incorrect. Documenting the client's understanding of adverse effects is important, but ensuring the client's knowledge about diaphragm use is the first step.

B. Incorrect. Teaching the client how to insert the diaphragm can be an important step, but first, it's essential to assess the client's existing knowledge.

C. Correct. Before proceeding with teaching or other actions, it's important to determine the client's baseline understanding of diaphragm use.

D. Incorrect. Supervising the return demonstration is important but should come after the client's knowledge level is assessed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

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A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

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