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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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Correct Answer is C

Explanation

A: Attaching the restraint to the bed's side rails can increase the risk of injury if the client tries to climb over them. The restraints should instead be attached to be bed frame.
B: Restraints should be removed at least every 2 hours to assess the client's condition and provide necessary care, not every 4 hours.

C: Documentation of the client's condition is essential to ensure proper monitoring and assessment while the restraint is in use.
D: PRN restraint prescriptions should not be used for clients who are aggressive; restraints should only be used as a last resort and with a clear medical justification.

A. Blood pressure B. Temperature C. Heart rate D. Oxygen saturation E. Travel history F. Weight G. Sputum characteristics H. Report of cough

Correct Answer is ["B","E","G","F","H"]

Explanation

A. While monitoring blood pressure is essential in the overall assessment of a patient, the given blood pressure readings (112/88 mm Hg) are within the normal range. Hence, further evaluation of blood pressure may not be immediately necessary based on the provided information.
B. A temperature of 38.1°C (100.5°F) indicates fever, which can be a sign of infection or inflammatory process. Further evaluation is warranted to determine the cause of the fever and initiate appropriate treatment.
C. The heart rate of 98/min falls within the normal range for adults (60-100 beats per minute). Although heart rate abnormalities can indicate various conditions, the given heart rate alone may not warrant immediate further evaluation without additional concerning symptoms or clinical context.
D. The oxygen saturation of 98% on room air is within the normal range (>95%).

While assessing oxygen saturation is crucial, the provided value does not indicate immediate concern. Further evaluation may be needed if the patient shows signs of respiratory distress or if there is clinical suspicion of hypoxemia.

E. Recent travel to South Africa raises concerns about potential exposure to infectious diseases endemic to that region. Further evaluation is necessary to assess for travel- related illnesses or infections, such as tuberculosis or other tropical diseases.
F. A significant weight loss of 2.26 kg (5 lb) over the last week is concerning and requires further investigation. Unintentional weight loss can be indicative of various underlying medical conditions, including infections, malignancies, or metabolic disorders.
G. The report of "blood-tinged sputum" suggests hemoptysis, which can be a sign of serious underlying conditions such as pulmonary infections, pulmonary embolism, or malignancy. Further evaluation is necessary to determine the cause and initiate appropriate management.
H. The presence of a persistent cough, especially when associated with other symptoms like fatigue, night sweats, and weight loss, raises concerns for underlying respiratory or systemic conditions. Further assessment is needed to identify the cause of the cough and provide appropriate treatment.

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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.

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Correct Answer is C

Explanation

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Correct Answer is ["B","E","G","F","H"]

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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.