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A nurse is caring for a client in a clinic.

Exhibit 1 Exhibit 2.

Nurses' Notes.

0900:

A16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths.

0910:.

Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorm, but the client admits that they have always been afraid of thunderstorms. Client admits smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They do attend school regularly and are on the honor roll.

Vital Signs.

0915:

Temperature 36.7° C (98° F).

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min.

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 follow-up.

BP 122/80 mmHg.

Heart rate 99/min.

Startles easy during thunderstorm.

Client experiences nightmares.

Witnessing their family’s death.

Caregiver reporting client acting differently than usual.

Attends school regularly.

Smoking marijuana to clear their mind.

Answer and Explanation

Correct Answer : B,D,E,H

• B: Heart rate 99/min. This is a finding that requires immediate follow-up because it is above the normal range for a 16-year-old client, which is 60 to 100 beats per minute. A high heart rate could indicate anxiety, stress, pain, infection or other conditions that need to be addressed.

• D: Client experiences nightmares. This is a finding that requires immediate follow-up because it could indicate post-traumatic stress disorder (PTSD), which is a mental health condition that can develop after witnessing or experiencing a traumatic event. PTSD can cause distressing symptoms such as nightmares, flashbacks, intrusive thoughts, avoidance, negative mood and hyperarousal. PTSD can interfere with the client’s daily functioning and well-being and requires professional treatment.

• E: Witnessing their family’s death. This is a finding that requires immediate follow-up because it is the most likely cause of the client’s PTSD symptoms and emotional distress. Witnessing the death of one’s family members is a devastating and traumatic experience that can have lasting effects on the client’s mental health. The client may benefit from grief counseling, trauma-focused therapy, medication or other interventions to help them cope with their loss and trauma.

• H: Smoking marijuana to clear their mind. This is a finding that requires immediate follow-up because it indicates that the client is using an illicit substance to self-medicate their emotional pain. Smoking marijuana can have negative effects on the client’s physical and mental health, such as impairing their memory, cognition, judgment, coordination and motivation. It can also increase the risk of addiction, dependence and withdrawal symptoms. The client may need substance abuse counseling, education, referral or other services to help them quit smoking marijuana and find healthier ways to cope with their feelings.
The other findings do not require immediate follow-up for the following reasons:

• A: BP 122/80 mmHg. This is not a finding that requires immediate follow-up because it is within the normal range for a 16-year-old client, which is 110 to 120/70 to 80 mmHg. A normal blood pressure indicates that the client’s cardiovascular system is functioning well and there are no signs of hypertension or hypotension.

• C: Startles easy during thunderstorm. This is not a finding that requires immediate follow-up because it is a normal reaction to a loud noise or a frightening stimulus. The client admits that they have always been afraid of thunderstorms, which suggests that this is not a new or unusual behavior for them. However, the nurse may want to monitor the client’s anxiety level and provide reassurance and comfort during thunderstorms.

• F: Caregiver reporting client acting differently than usual. This is not a finding that requires immediate follow-up because it is a vague and subjective statement that does not specify how the client is acting differently or what changes have occurred in their behavior. The nurse may want to ask the caregiver for more details and examples of how the client has changed since the traumatic event and assess whether these changes are normal or concerning.

• G: Attends school regularly. This is not a finding that requires immediate follow-up because it indicates that the client is maintaining their academic performance and social interactions despite their trauma and grief. Attending school regularly can provide the client with a sense of routine, structure, support and achievement that can help them cope with their situation. However, the nurse may want to check with the client’s teachers and peers to see if they have noticed any changes in the client’s mood, behavior or participation at school.

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Correct Answer is C

Explanation

The correct answer is choice C. Perform the procedure prior to meals.

This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs.

If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.

Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.

Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.

Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.

Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.

A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.

A. Administer naloxone to the newborn. B. Minimize noise in the newborn's environment. C. Swaddle the newborn with his leg extended. D. Maintain eye contact with the newborn during feedings.

Correct Answer is B

Explanation

Choice A reason
Administering naloxone to the newborn is not appropriate. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose in adults. It is not typically used for newborns with neonatal abstinence syndrome. The management of NAS is primarily supportive, and medications may be prescribed to help manage specific withdrawal symptoms, but naloxone is not a standard treatment for NAS.

Choice B reason:

Minimizing noise in the newborn's environment is a crucial action in the plan of care is the correct action to be included. Newborns experiencing NAS can be easily overstimulated, and loud noises can exacerbate their withdrawal symptoms and distress. Creating a calm and quiet environment helps reduce agitation and promotes better sleep and overall comfort.

Choice C reason

Swaddling the newborn with his leg extended is not appropriate in this case. Swaddling can be beneficial for some newborns, but the specific positioning and swaddling techniques should be individualized based on the newborn's needs and preferences. Extending the newborn's legs may not necessarily be the best approach, as it may not provide comfort or address the symptoms associated with NAS.

Choice D reason:

Maintaining eye contact with the newborn during feedings is not appropriate in this case. While maintaining eye contact during feedings is an essential aspect of bonding and promoting parent-newborn attachment, it may not be the primary focus in managing neonatal abstinence syndrome. The plan of care for a newborn with NAS would primarily involve managing withdrawal symptoms, providing comfort measures, and addressing the newborn's unique needs during this challenging period.

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