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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 C

Explanation

A.Jogging or any form of vigorous exercise, especially high-impact activities, should generally be avoided for at least 4–6 weeks after retinal surgery. This is because high-impact activities can increase intraocular pressure and potentially disrupt the healing retina. Jogging involves bouncing or jolting movements, which could adversely affect the repair.

B. Bending at the waist places increased pressure on the eye and can disrupt the healing process after retinal surgery. This action increases intraocular pressure and is typically discouraged postoperatively.

C. Light lifting, such as lifting objects under 10 pounds, is typically allowed after several weeks of recovery, once the initial healing has occurred and the client is no longer at risk for increasing intraocular pressure or straining the surgical site.

D. While sewing itself is a low-impact activity, the act of sewing typically involves bending over or placing the head below the waist, which could still increase intraocular pressure. Early postoperative instructions often caution against activities that involve bending or straining the eyes, such as sewing, reading, or watching TV for extended periods.

D. Correct. After surgical repair of a detached retina, clients should avoid activities that might increase intraocular pressure, like heavy lifting or bending at the waist. Activities that do not strain the eye, like sewing, can typically be resumed earlier.

A. Arrange for the nurses to have as few shifts together as possible. B. Encourage collaboration between the two nurses when making assignments. C. Tell the nurses that the assignments will be more equitable in the future. D. Ask each nurse to take turns making the assignments.

Correct Answer is B

Explanation

A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.

B. Correct. Encouraging collaboration empowers the nurses to work together and find common ground in making assignments.

C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.

D. Incorrect. Asking each nurse to take turns making the assignments might not resolve the perceived favoritism and could create further tension.

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Select the 4 findings that require follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory results of a client who is receiving total parenteral nutrition.Which of the following results should the nurse identify as an indication that the client has developed a common complication of this nutritional therapy?

A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?

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 providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?

A nurse is caring for a client who has Crohn's disease.The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

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?