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A nurse is caring for a client in a clinic.

Exhibits

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

Answer and Explanation

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

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. While a cooling blanket may be indicated to reduce fever associated with a thyroid storm, the priority lies in monitoring the cardiac rhythm for potential life-threatening complications such as tachycardia or arrhythmias.
B. Thyroid storm can precipitate severe cardiac complications, making continuous monitoring of the client's cardiac rhythm imperative to detect any abnormalities promptly.
C. Administering IV fluids may be necessary to address dehydration, but it is not the priority over monitoring the cardiac rhythm.
D. While monitoring blood glucose levels is important, it is not the immediate priority in managing a thyroid storm.

A. Choose foods high in vitamin B12- B. Choose high-fat cheese as a meat substitute. C. Limit intake of nuts and legumes. D. Limit intake of foods high in vitamin C.

Correct Answer is A

Explanation

A. Since vitamin B12 is primarily found in animal products, clients following a vegan diet should be advised to consume fortified foods or supplements containing vitamin B12 to prevent deficiency.
B. High-fat cheese is not a suitable meat substitute for individuals following a vegan diet, as it is an animal-derived product.
C. Nuts and legumes are valuable sources of protein and other nutrients in a vegan diet and should not be limited unless there are specific dietary restrictions or preferences.
D. Foods high in vitamin C are beneficial for overall health, but limiting them is not necessary for individuals following a vegan diet.

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A nurse is caring for a client in a clinic. Exhibits 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.

Nursing Test Bank

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A nurse is caring for a client in a clinic.

Exhibits

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.