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 C
Explanation
A. Constipation is a potential side effect of morphine, but it is not the priority concern in this scenario.
B. Euphoria is a potential side effect of morphine but is not as immediately concerning as bradypnea.
C. Correct. Bradypnea (slow breathing) is a potential adverse effect of morphine and can lead to respiratory depression, which is a serious concern.
D. Sedation is an expected side effect of morphine, but the priority concern is the possibility of respiratory depression.
Correct Answer is D
Explanation
A. Incorrect. Polyhydramnios (excessive amniotic fluid) is not typically associated with placenta previa. It can be associated with conditions like fetal abnormalities or maternal diabetes.
B. Incorrect. Uterine tenderness might be present in conditions like uterine contractions, but it is not a primary finding in placenta previa.
C. Incorrect. Nausea is a common pregnancy symptom and is not directly related to placenta previa.
D. Correct. Spotting or painless vaginal bleeding is a hallmark sign of placenta previa, which occurs when the placenta covers part or all of the cervix. It can be life-threatening if severe bleeding occurs.
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