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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Incorrect. Mild swelling under the sutures is a common finding after surgery and may not necessarily require reporting unless it worsens or is associated with other concerning symptoms.
B. Incorrect. Pink-tinged coloration can be a normal part of the healing process, as long as there is no excessive redness, warmth, or signs of infection.
C. Incorrect. Crusting of exudate on the incisional line can occur during the healing process and may not necessarily indicate a problem unless it's accompanied by signs of infection.
D. Correct. Partial separation of the upper part of the incisional line can indicate wound dehiscence, a potential complication that requires immediate attention to prevent infection and further complications.

A. Measure gastric residual volumes every 4 hr. B. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication. C. Maintain the head of the bed at a 20° angle. D. Advance the rate of the feeding every 2 hr.

Correct Answer is A

Explanation

A. Correct. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.

B. Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.

C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.

D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

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