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.

Assessment of adolescents following severe traumatic events involves identifying manifestations of acute stress reactions, maladaptive coping behaviors, and risk factors for developing Post-traumatic stress disorder or other mental health disorders. Exposure to the sudden death of close family members during a natural disaster is a profound psychological trauma that can lead to intrusive memories, avoidance behaviors, substance use, anxiety, and functional impairment. Nurses must prioritize findings that indicate unresolved trauma, impaired coping, or behaviors that increase risk to the client’s mental and physical health. Early recognition and intervention are essential in preventing worsening psychological distress.

Rationale:
A. Experiencing nightmares requires immediate follow-up because recurrent distressing dreams are a hallmark symptom of trauma-related disorders such as acute stress disorder or PTSD. These nightmares indicate persistent re-experiencing of the traumatic event and may significantly impair sleep quality and emotional regulation. In adolescents, chronic sleep disruption can worsen anxiety, depression, irritability, and concentration difficulties, increasing the need for psychological evaluation and support.

B. Startling easily during thunderstorms may represent hyperarousal related to trauma exposure, but the client reports a preexisting fear of thunderstorms before the tornado occurred. This finding alone does not clearly indicate worsening psychiatric instability or immediate danger. Although it should be monitored, it is not as urgent as indicators of active maladaptive coping or severe trauma-related symptoms.

C. A blood pressure of 122/80 mm Hg is within expected limits for a 16-year-old adolescent and does not indicate acute physiological instability. Mild sympathetic activation can occur in anxious clients, but this value does not suggest hypertensive crisis, shock, or cardiovascular compromise. Therefore, it does not require immediate nursing follow-up.

D. Smoking marijuana to “clear their mind” requires immediate follow-up because it reflects maladaptive coping and substance use following a traumatic event. Adolescents who use substances after trauma are at increased risk for dependency, impaired judgment, worsening depression, and interference with healthy emotional processing. Substance use may also mask worsening psychiatric symptoms and delay appropriate mental health treatment.

E. Witnessing the death of their parents and sibling is a severe traumatic exposure that places the client at high risk for acute stress disorder, PTSD, complicated grief, depression, and suicidal ideation. The violent and sudden loss of immediate family members significantly increases psychological vulnerability, especially in adolescents. This history requires urgent emotional assessment, safety evaluation, and referral for trauma-focused mental health interventions.

F. Attending school regularly is generally a positive adaptive behavior and suggests partial preservation of daily functioning despite recent trauma. Continued participation in academics and maintenance of honor-roll performance indicate some degree of coping and structure. While emotional support is still necessary, this finding alone does not represent an immediate concern requiring urgent follow-up.

G. A friend reporting that the client is “not themselves” requires immediate follow-up because behavioral changes noticed by peers may indicate worsening emotional distress, withdrawal, depression, or altered functioning. Adolescents often minimize symptoms during direct questioning, making collateral observations highly valuable. Sudden personality or behavioral changes after trauma can signal significant psychological deterioration requiring further assessment.

H. A heart rate of 99/min is within the upper range of normal for an adolescent and may occur due to anxiety or emotional stress during the clinic visit. There are no accompanying signs of cardiovascular instability such as hypotension, chest pain, or respiratory distress. Therefore, this finding does not require immediate intervention compared with the psychological concerns present.