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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.

A.

Attends school regularly

B.

Caregiver reporting client acting differently than usual

C.

Witnessing their family's death

D.

Heart rate 99/min

E.

Smoking marijuana to clear their mind

F.

Client experiences nightmares

G.

Client experiences nightmares

H.

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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Related Questions

Correct Answer is ["C","E"]

Explanation

A. Placenta previa: The client's symptoms do not specifically suggest placenta previa, which is characterized by painless vaginal bleeding, not back pain.
B. Disseminated intravascular coagulation: The client's symptoms and vital signs do not suggest disseminated intravascular coagulation, which is a serious condition characterized by excessive bleeding and clotting throughout the body.
C. Preeclampsia: The presence of uterine contractions, elevated blood pressure, and a potential increase in body temperature can indicate the risk of developing preeclampsia, a condition characterized by high blood pressure and signs of damage to other organ systems, often developing after the 20th week of pregnancy.
D. Sepsis: While the client has an elevated temperature, the symptoms provided do not strongly indicate sepsis. Other signs, such as rapid heart rate, low blood pressure, and changes in mental status, are usually associated with sepsis.
E. Preterm prelabour rupture of membranes (PROM): The client's report of lower back pain, pinkish vaginal discharge, and uterine contractions can raise concern for the risk of preterm prelabour rupture of membranes, where the amniotic sac ruptures before the onset of labor.
F. Seizures: The client's symptoms and information provided do not indicate a risk of seizures. Seizures can be associated with conditions like preeclampsia but are not directly indicated by the client's current assessment.

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.

Membranes intact.

No uterine contractions noted.

FHR baseline 138, with minimal variability. No further reports of burning with urination.

Laboratory Results: WBC 12,000/mm3 (within the normal range of 5,000 to 10,000/mm3). Platelet count 188,000/mm3 (within the normal range of 150,000 to 400,000/mm3).

Vital Signs: Temperature 37.1°C (98.7°F), Blood pressure 120/78 mm Hg.

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