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A nurse is assisting with the care of client in a clinic.

Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.

Witnessing the death of their parents and sibling

Attends school regularly

Client experiences nightmares

Blood pressure 122/80 mm Hg

Heart rate 99/min

Startles easy during thunderstorm

Friend reporting client is not themselves

Smoking marijuana to clear their mind

Answer and Explanation

Correct Answer : A,C,G,H

A. Witnessing the death of their parents and sibling: Experiencing such severe trauma places the client at high risk for post-traumatic stress disorder (PTSD) and complicated grief. Immediate follow-up is necessary to assess emotional safety and provide appropriate mental health interventions.

B. Attends school regularly: Regular school attendance is a positive sign of functioning and does not require immediate follow-up. It indicates that the client maintains some level of daily routine and social engagement.

C. Client experiences nightmares: Nightmares following trauma can indicate PTSD or acute stress reaction. These symptoms warrant prompt assessment and intervention to prevent worsening sleep disturbances, anxiety, or functional impairment.

D. Blood pressure 122/80 mm Hg: This is within normal limits for a 16-year-old and does not require immediate follow-up. It is not indicative of acute physical risk.

E. Heart rate 99/min: While slightly elevated, this heart rate is within a mild range of normal for adolescents under stress and does not require immediate follow-up unless accompanied by other acute symptoms.

F. Startles easily during thunderstorms: A mild startle response, especially with a prior fear of storms, is not an urgent concern. While it may relate to trauma, it is not immediately dangerous or requiring urgent follow-up.

G. Friend reporting client is not themselves: Changes in behavior observed by peers can indicate worsening mental health or risk of self-harm. Immediate follow-up is important to evaluate mood, coping, and safety.

H. Smoking marijuana to clear their mind: Self-medicating with substances is a significant safety concern, particularly in adolescents coping with trauma. Immediate follow-up is required to assess for substance use disorder and potential harm to mental and physical health.

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Correct Answer is B

Explanation

A. Polio: The inactivated polio vaccine does not contain live virus and does not increase bleeding risk in clients with thrombocytopenia. It is generally considered safe to administer and does not worsen platelet destruction. Routine immunization schedules can usually be continued with this vaccine.

B. Measles, mumps, and rubella virus: The MMR vaccine is a live attenuated vaccine and is associated with the development or worsening of thrombocytopenia. In a client with idiopathic thrombocytopenic purpura, this vaccine should be withheld due to the risk of further platelet reduction and bleeding complications. Careful timing or deferral is recommended until platelet counts stabilize.

C. Diphtheria and tetanus toxoids and pertussis: This vaccine is inactivated and does not pose a risk of viral replication or immune-mediated platelet destruction. While injection technique may need to be adjusted to reduce bleeding risk, the vaccine itself is not contraindicated.

D. Hepatitis B: Hepatitis B vaccine is non-live and safe for clients with thrombocytopenia. Although intramuscular injections can increase the risk of localized bleeding, the vaccine itself does not exacerbate ITP. Applying firm pressure after injection helps minimize bruising or hematoma formation.

A. Limit the client's social interactions. B. Maintain a verbal no harm contract with the client C. Assume responsibility for making the clients decisions. D. Encourage the client to be assertive

Correct Answer is D

Explanation

A. Limit the client's social interactions: Limiting social interactions can increase dependence and isolation, worsening the symptoms of dependent personality disorder. Encouraging appropriate social engagement supports skill-building and autonomy.

B. Maintain a verbal no harm contract with the client: No-harm contracts are typically used in clients at risk for self-harm or suicide. Dependent personality disorder does not inherently involve self-harm, so this instruction is not a priority in discharge teaching.

C. Assume responsibility for making the client’s decisions: Making decisions for the client reinforces dependency and undermines the development of autonomy. The goal of teaching is to promote independent decision-making and self-confidence.

D. Encourage the client to be assertive: Teaching the client to express needs, make choices, and assert themselves helps reduce reliance on others and fosters self-efficacy. Encouraging assertiveness is a key strategy in managing dependent personality disorder.

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A nurse is assisting with the care of client in a clinic. Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.

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A nurse is assisting with the care of client in a clinic.

Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.