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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 A

Explanation

The correct answer is Choice A.

Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.

Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.

Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.

Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.

A. "Participate in range-of-motion exercises." B. "Place a pillow under your knees while in bed." C. "Remain on bed rest for 24 hours following the procedure." D. "Use an incentive spirometer every 4 hours."

Correct Answer is A

Explanation

A. Correct. Participating in range-of-motion exercises helps prevent circulation problems and joint stiffness that can result from prolonged immobility after surgery.

B. Incorrect. While elevating the knees can help reduce strain on the lower back, this might not specifically promote circulation.

C. Incorrect. Prolonged bed rest can lead to decreased circulation and increased risk of complications such as deep vein thrombosis (DVT).

D. Incorrect. While using an incentive spirometer is important for preventing respiratory complications, it might not specifically address circulation issues.

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Select the 4 findings that require follow-up.

Nursing Test Bank

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A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?

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Correct Answer is A

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