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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. A metallic taste in the mouth is not a common adverse effect of sertraline.
B. Correct. Excessive sweating (diaphoresis) is a potential adverse effect of sertraline and other selective serotonin reuptake inhibitors (SSRIs).
C. Incorrect. Increased urinary frequency is not commonly associated with sertraline.
D. Incorrect. A dry cough is not a known adverse effect of sertraline.
Correct Answer is D
Explanation
A. Incorrect. Acute glomerulonephritis can cause fluid retention and hypertension, rather than hypotension.
B. Incorrect. Weight gain might occur due to fluid retention rather than weight loss.
C. Incorrect. Decreased urine output, not polyuria, is a common finding in acute glomerulonephritis.
D. Correct. Hematuria (blood in the urine) is a classic sign of acute glomerulonephritis, reflecting inflammation and damage to the glomeruli in the kidneys.
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