A nurse is caring for a 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 follow-up.
Smoking marijuana to clear their mind
BP 122/80 mm Hg
Witnessing their family's death
Attends school regularly
Client experiences nightmares
Startles easy during thunderstorm
Heart rate 99/min
Caregiver reporting client acting differently than usual
Correct Answer : A,C,E,F,H
A. Smoking marijuana to clear their mind
Using marijuana to cope with emotional pain or trauma is concerning. It suggests that the client may be turning to substances to manage their stress, anxiety, or trauma-related symptoms, which could lead to substance use disorder. It is important to address the substance use as it may hinder the healing process, especially given the trauma the client has experienced.
B. BP 122/80 mm Hg
This blood pressure reading is within the normal range for a 16-year-old. A blood pressure of 120/80 mm Hg or lower is generally considered normal for adolescents, so there is no immediate need for follow-up regarding this finding. This vital sign does not indicate an urgent issue.
C. Witnessing their family's death
Witnessing the violent deaths of close family members is a major traumatic event that can lead to post- traumatic stress disorder (PTSD), complicated grief, or other mental health issues. This experience is significant and requires immediate follow-up to assess how the client is processing the trauma and to ensure they are receiving appropriate mental health support, such as therapy or counseling.
D. Attends school regularly
While it's important to monitor the client’s social and academic functioning, attending school regularly is a positive indicator. The client is able to continue their education despite their trauma, which is a sign of resilience. However, this finding does not require immediate follow-up, but ongoing assessment may be needed to evaluate if there are any underlying issues affecting their school performance or social interactions.
E. Client experiences nightmares
Nightmares, particularly those related to a traumatic event, are a common symptom of post-traumatic stress disorder (PTSD). Since the client witnessed the traumatic deaths of their family members, this could be part of a larger pattern of distress. Follow-up is needed to evaluate the severity of the nightmares and determine whether the client needs trauma-focused therapy or other interventions to address potential PTSD symptoms.
F. Startles easily during thunderstorms
This is a common symptom of hypervigilance, which is associated with PTSD or acute stress disorder (ASD) following trauma. The client’s startle response, particularly in response to thunderstorms (which could be a trigger), warrants immediate follow-up. The nurse should assess the client's emotional response to stimuli and provide guidance on managing triggers, as well as explore whether the client needs therapy or trauma-informed care.
G. Heart rate 99/min
A heart rate of 99 beats per minute is within the normal range for adolescents and is not concerning on its own. While anxiety or stress could cause a mild increase in heart rate, this finding does not require immediate intervention unless there are other signs of distress, such as chest pain or difficulty breathing.
H. Caregiver reporting client acting differently than usual
A change in behavior, as reported by the caregiver, is concerning. It may indicate that the client is struggling emotionally or mentally, particularly after experiencing such a traumatic loss. This behavior could be linked to depression, anxiety, or trauma-related symptoms, and therefore requires immediate follow-up to assess the client's mental health and ensure that they are receiving appropriate support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encouraging the client to watch television might distract them, but it does not provide the comfort and reassurance needed during a panic attack.
B. Sitting with the client provides a sense of security and reassurance, helping them feel safe during a panic attack. It is essential to stay calm and supportive.
C. Atomoxetine is a medication for ADHD and would not be appropriate for managing anxiety during a panic attack.
D. Teaching the client how to meditate is helpful in the long term but is not the most immediate and effective intervention during a panic attack.
Correct Answer is B
Explanation
A. Hypotension is not typically associated with acute glomerulonephritis. Instead, hypertension is more commonly seen due to fluid retention and increased vascular resistance.
B. Hematuria is a hallmark finding of acute glomerulonephritis. This condition often leads to blood in the urine, which can be seen as reddish or smoky-colored urine.
C. Weight loss is not typically associated with acute glomerulonephritis. Weight gain is more common due to fluid retention and edema caused by impaired kidney function.
D. Polyuria (excessive urination) is generally not expected in acute glomerulonephritis. Instead, oliguria (decreased urine output) is more typical, as kidney function is impaired and fluid retention occurs.
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