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
Client experiences nightmares
Startles easy during thunderstorm
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Securing the tracheostomy tube with ties is important, but this is a task that should be performed by healthcare professionals initially. It is not typically part of discharge teaching.
B. Incorrect. Changing the tracheostomy dressing using clean technique is also an essential skill but may not be suitable for discharge teaching. The partner should be educated on monitoring the stoma site and recognizing signs of infection or complications.
C. Correct. Teaching the partner how to operate the portable suction machine is crucial for maintaining a patent airway. Suctioning is often necessary to clear mucus and secretions from the tracheostomy tube, especially when the client is at home.
D. Incorrect. Changing a tracheostomy tube, particularly a nondisposable one, is a procedure that should be performed by healthcare professionals due to the risk of complications and the need for sterile technique. It is not typically part of discharge teaching to non-medical caregivers.
Correct Answer is D
Explanation
Choice A rationale:
Decreased temperature is not a typical sign of naloxone reversing the effects of an opioid overdose. Opioid overdose commonly leads to respiratory depression and hypoxia, but it does not significantly affect body temperature. Naloxone works by binding to the same receptors in the brain that opioids bind to, thereby reversing the effects of the overdose. The primary signs of successful reversal include improved respiratory rate and increased alertness, not changes in body temperature.
Choice B rationale:
Polyuria (excessive urination) is not a specific indicator of naloxone effectiveness. Opioid overdose and naloxone administration primarily affect the central nervous system and respiratory function, not urinary output. Naloxone's effects are more evident in the client's level of consciousness, respiratory rate, and overall responsiveness.
Choice C rationale:
Bradycardia (slow heart rate) is not an expected indicator of naloxone effectiveness. Opioid overdose typically causes respiratory depression, leading to a decreased respiratory rate and oxygen saturation. Naloxone works by reversing this respiratory depression and improving ventilation. Consequently, increased respiratory rate, not heart rate, is a more relevant indicator of naloxone's effectiveness in reversing opioid overdose.
Choice D rationale:
This is the correct answer. Increased respiratory rate is a key indicator that naloxone is reversing the effects of an opioid overdose. Opioid overdose depresses the respiratory system, leading to slow and shallow breathing. Naloxone, as an opioid receptor antagonist, rapidly reverses this effect, leading to a noticeable increase in the client's respiratory rate. Monitoring for improved breathing and increased oxygen saturation is crucial to assessing the effectiveness of naloxone in treating opioid overdose.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.