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Select the 4 findings that require follow-up.

Witnessing their family's death

Caregiver reporting client acting differently than usual

Attends school regularly

Startles easy during thunderstorm

Heart rate 99/min

BP 122/80 mmHg

Smoking marijuana to clear their mind

Client experiences nightmares

Answer and Explanation

Correct Answer : A,B,D,H

Based on the information provided, the following findings require immediate follow-up:

A. Witnessing their family's death: The client witnessing their family's death during the tornado is a traumatic event that may have significant psychological implications. This finding requires immediate attention and further assessment to address the client's emotional well-being.

B. Caregiver reporting client acting differently than usual: The caregiver's concern about the client "not being themselves lately" is important and may indicate changes in the client's behavior or mental state. This requires immediate follow-up to explore the reasons behind the change in behavior.

D. Startles easily during thunderstorm: The client's heightened startle response during thunderstorms may be indicative of increased anxiety or trauma-related symptoms. This finding requires further evaluation and intervention.

G. Smoking marijuana to clear their mind: The client's use of marijuana to cope with their emotions and thoughts indicates maladaptive coping mechanisms. This finding requires immediate follow-up to address substance use and provide appropriate support.

H. Client experiences nightmares: The client's nightmares are likely related to the traumatic event they witnessed, and they may be experiencing symptoms of post-traumatic stress disorder (PTSD). This finding requires immediate attention and assessment to provide appropriate mental health support.

The other findings mentioned (C, E, F) are not concerning based on the information provided and do not require immediate follow-up. However, they may still be relevant for the client's overall assessment and care plan. The nurse should prioritize addressing the immediate mental health and emotional needs of the client, given the recent traumatic experience they went through.

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Correct Answer is D

Explanation

A. Incorrect. Restraints should be removed and repositioned, and the client's needs assessed at a frequency that follows institutional policies, which might not always be every 4 hours.

B. Incorrect. Restraints should be attached to the bed frame, not the side rails, to minimize the risk of injury.

C. Incorrect. PRN (as needed) restraint prescriptions should be avoided. Restraints should only be used based on specific criteria and under the guidance of a healthcare provider.

D. Correct. When using restraints, it's important to document the client's condition frequently to assess for any potential adverse effects or discomfort.

A. Administer a cathartic suppository 30 min prior to scheduled defecation times. B. Encourage a maximum fluid intake of 1,500 mL per day. C. Increase the amount of refined grains in the client's diet. D. Provide the client with a cold drink prior to defecation.

Correct Answer is A

Explanation

A. Correct. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.

B. Incorrect. Adequate fluid intake is important, but limiting fluid intake is not typically recommended for clients with spinal cord injuries.

C. Incorrect. Refined grains are not specifically indicated for promoting bowel function. A balanced diet with sufficient fiber is more appropriate.

D. Incorrect. Providing a cold drink prior to defecation might not have a significant impact on bowel function and is not a commonly recommended intervention.

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Select the 4 findings that require follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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