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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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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Storing unused patches in the refrigerator is not necessary for transdermal scopolamine patches. Refrigeration is not a requirement for their storage.

Choice B rationale:

Applying the patch prior to traveling is the correct choice. Transdermal scopolamine patches are used to prevent motion sickness. Applying the patch before the journey allows the medication to be absorbed before exposure to motion, ensuring its effectiveness during travel.

Choice C rationale:

Placing the patch on the upper arm is a specific and correct instruction for applying transdermal scopolamine patches. The patch should be placed on a clean, dry, and hairless area of the skin, preferably behind the ear or on the upper arm.

Choice D rationale:

Replacing a dislodged patch onto the same location is incorrect. If the patch becomes dislodged, it should be replaced with a new patch on a different, clean, and dry area of the skin. Reapplying a dislodged patch to the same spot may result in uneven absorption and reduced effectiveness.

A. Improved short-term memory B. Increased food intake C. Can perform ADLs independently D. Enhanced mood

Correct Answer is A

Explanation

A. Correct. Donepezil is a medication used to treat Alzheimer's disease and is expected to improve cognitive function, including short-term memory.

B. Incorrect. Donepezil is not typically associated with changes in food intake.

C. Incorrect. While improved functional ability is a goal of treatment, performing ADLs independently might not be solely indicative of donepezil's effectiveness.

D. Incorrect. Donepezil is primarily focused on improving cognitive function rather than mood enhancement.

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Select the 4 findings that require follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about using transdermal scopolamine to treat motion sickness.Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

Correct Answer is A

Explanation

A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?

A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect?

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?