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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 D

Explanation

A. Milk products can exacerbate symptoms of irritable bowel syndrome in some individuals, especially those with lactose intolerance, and are generally not recommended.
B. Foods sweetened with fructose corn syrup may exacerbate symptoms of irritable bowel syndrome in some individuals and are best avoided.
C. Gluten-containing foods may trigger symptoms in individuals with irritable bowel syndrome, particularly those with gluten sensitivity or celiac disease, and should be limited or avoided as appropriate.
D. Increasing intake of foods high in bran fiber can help regulate bowel movements and alleviate symptoms of constipation, which is often a concern for individuals with irritable bowel syndrome.

A. Apply lotion to skin every 4 hr. B. Supplement feeding with sterile water. C. Brestfeed every 2 to 3 hr. D. Cover newborn's eyes with a shield. E. Dress in only a diaper.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A. Applying lotion to the skin is contraindicated during phototherapy because it can interfere with the effectiveness of the therapy by blocking the light from reaching the skin. B. Supplementing feeding with sterile water is contraindicated because it can decrease the newborn's intake of breast milk or formula, which is essential for hydration and nutrition, especially during phototherapy. C. Breastfeeding is indicated and encouraged every 2 to 3 hours because it helps to maintain hydration and promotes bilirubin excretion, which can help in reducing jaundice levels. D. Covering the newborn's eyes with a shield is indicated during phototherapy to protect the eyes from the bright lights used in the treatment, which can potentially damage the retina and cause eye problems. E. Dressing the newborn in only a diaper is indicated during phototherapy to maximize the exposure of the skin to the light, which enhances the effectiveness of the treatment in reducing bilirubin levels.

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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

Naxlex Comprehensive Predictor Exams

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a 36-hr old infant. Exhibits For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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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.