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.
Client experiences nightmares
Heart rate 99/min
Attends school regularly
Smoking marijuana to clear their mind
Startles easy during thunderstorm Witnessing their family's death
BP 122/80 mm Hg
Caregiver reporting client acting differently than usual
Correct Answer : A,D,E,G
A. The client's nightmares could be indicative of post-traumatic stress disorder (PTSD), especially after the client’s parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago.
B. A heart rate of 99/min is within the normal range for the client’s age and requires no need for follow-up.
C. While regular attendance at school is generally considered a positive behavior, it does not directly indicate a need for immediate follow-up. However, it is relevant information for assessing the client's overall functioning and resilience in the context of their recent traumatic experience.
D. The client's use of marijuana as a coping mechanism raises concerns about their mental health and potential substance abuse. Immediate follow-up is needed to address this issue and provide appropriate support and intervention.
E. Startles easily during thunderstorms and witnessing their family's death are findings that indicate symptoms of post-traumatic stress disorder (PTSD) or acute stress reaction following the traumatic event of witnessing their family's death. Immediate follow-up is
necessary to assess the client's mental health status and provide appropriate support and counseling.
F. A blood pressure of 122/80 mm Hg falls within the normal range for adolescents and does not indicate an immediate medical concern. While blood pressure monitoring is important for overall health assessment, this finding alone does not warrant immediate follow-up in the context of the client's presenting issues.
G. The caregiver's observation that the client is acting differently than usual suggests a change in behavior or mental health status that requires further assessment and intervention. Immediate follow-up is needed to explore the caregiver's concerns and address any underlying issues affecting the client's well-being
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Flattening of the artificial airway cuff. This would indicate a problem, such as a leak, not a successful outcome of suctioning.
B. This indicates that the airway resistance has been reduced following suctioning, which suggests that the suctioning was effective in clearing the airway obstruction caused by secretions.
C. Thinning of mucous secretions is not a direct indication of effective suctioning; while thinner secretions may be easier to remove, the goal of suctioning is to clear the airways rather than alter the consistency of the secretions.
D. The presence of a productive cough is not relevant in the context of a patient who is intubated and mechanically ventilated, as they would be unable to cough effectively due to the endotracheal tube.
Correct Answer is C
Explanation
A. Prealbumin levels are often used as a marker of nutritional status and can indicate protein deficiency. A low prealbumin level may suggest malnutrition or inadequate protein intake. However, the prealbumin level of 25 mg/dL is within the normal range (normal range typically 15-35 mg/dL), so it does not require immediate reporting to the provider.
B. The client's temperature of 37.6°C (99.7°F) is slightly elevated but is not indicative of a fever (typically defined as ≥38°C or 100.4°F). This finding may suggest a mild increase in body temperature, which could be related to various factors such as dehydration, infection, or environmental factors. Since it's only slightly elevated and within a
borderline range, it may not require immediate reporting unless other concerning symptoms are present.
C. Urine specific gravity measures the concentration of solutes in the urine and can indicate hydration status. A specific gravity of 1.035 is considered high and may suggest concentrated urine, which could be a sign of dehydration or renal dysfunction. Therefore, this finding should be reported to the provider for further evaluation.
D. Hypoactive bowel sounds indicate decreased or absent bowel motility and can be a sign of gastrointestinal dysfunction, such as ileus or obstruction. While it's important to monitor bowel sounds and report any significant changes to the provider, hypoactive bowel sounds alone may not always require immediate reporting unless other concerning symptoms are present.
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