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A nurse is caring for a client in a clinic.

Vital Signs 0915:

Temperature 36.7° C (98° F)

BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min

Nurses' Notes 0900:

A 16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivors and witnessed their family's deaths.

0910:

The client appears anxious but answers appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorms, but the client admits that they have always been afraid of thunderstorms. The client admits to smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They attend school regularly and are on the honor roll.

Based on the information in the client's medical record, which of the following findings requires immediate follow-up?

Select the 4 findings that require follow-up.

Attends school regularly

Caregiver reporting client acting differently than usual

Witnessing their family's death

Heart rate 99/min

Smoking marijuana to clear their mind

Client experiences nightmares

Startles easy during thunderstorm

Answer and Explanation

Correct Answer : B,C,E,F

A.   Attends school regularly: While attending school regularly is important, it is not an immediate concern that requires follow-up compared to the other more pressing issues related to the traumatic event and the client's mental well-being.
B.   Caregiver reporting client acting differently than usual: This finding requires immediate follow-up because it indicates a change in the client's behavior and could be indicative of emotional distress or mental health issues, especially considering the recent traumatic event they experienced.

C.   Witnessing their family's death: Witnessing the death of family members in a traumatic event like a tornado is a significant and potentially traumatizing experience that requires immediate follow-up and support.
D.   Heart rate 99/min: While a heart rate of 99/min is slightly elevated, it is not a critical finding that requires immediate follow-up in this context. The other findings are more relevant to the client's psychological well-being.
E.   Smoking marijuana to clear their mind: The client's use of marijuana to cope with their thoughts and feelings should be addressed promptly, as it could indicate maladaptive coping mechanisms or potential substance abuse.
F.   Client experiences nightmares: Experiencing nightmares could be a symptom of post-traumatic stress disorder (PTSD) or other mental health concerns related to the traumatic event.
G.   BP 122/80 mm Hg: A blood pressure of 122/80 mm Hg is within a normal range and is not a cause for immediate concern.
H.   Startles easy during thunderstorm: While startle responses can be related to anxiety, this specific finding is not as pressing as the client's reported coping mechanisms and traumatic experiences.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale:

Changing the inner cannula on a tracheostomy is within the legal scope of practice for registered nurses. Nurses are trained to perform tracheostomy care, including changing the inner cannula. This procedure is within the nursing scope of practice and does not require a physician's intervention.

Choice B rationale:

Inserting a tunneled central venous catheter (such as a Hickman line) is a specialized procedure that generally falls under the scope of practice for advanced practice nurses (such as nurse practitioners or clinical nurse specialists) or physicians. RNs typically do not have the required training or authority to perform this invasive procedure.

Choice C rationale:

Irrigation of an external ear canal is within the legal scope of practice for registered nurses. Ear irrigation is a common nursing procedure used to remove impacted cerumen (earwax) and foreign bodies from the ear canal. Nurses are trained to perform this procedure safely and effectively.

Choice D rationale:

Administering blood products, including platelet transfusions, is within the legal scope of practice for an RN. RNs are responsible for preparing, verifying, and administering blood products according to institutional policies and procedures. This includes monitoring the patient during and after the transfusion for any adverse reactions.

A. "Think about a positive outcome to a stressful situation.” B. "Tighten a muscle group, then release the tension and move to the next one.” C. "Picture taking the stress you feel and pushing it down and out of your feet.” D. "Focus on a pleasant memory and express your emotions in writing.”

Correct Answer is B

Explanation

Choice B rationale:

Teaching the client to tighten a muscle group, release the tension, and then move to the next one is a technique used in progressive muscle relaxation (PMR) PMR is a stress management technique that involves tensing and relaxing different muscle groups to reduce muscle tension and promote relaxation. This method helps individuals become more aware of the sensations associated with muscle tension and relaxation, making it an effective strategy for managing anxiety and stress.

Choice A rationale:

Thinking about a positive outcome to a stressful situation is a cognitive-behavioral technique that can help shift the client's focus from negative thoughts to positive ones. While this technique can be beneficial, it does not specifically pertain to progressive relaxation as described in choice B.

Choice C rationale:

Picturing taking the stress and pushing it out of the feet is a visualization technique, which can be helpful for some individuals in managing stress. However, it is not a component of progressive relaxation as described in choice B.

Choice D rationale:

Focusing on a pleasant memory and expressing emotions in writing is a form of journaling or expressive writing, which can be a therapeutic technique for managing emotions and stress. While it can be a helpful strategy, it is not the same as progressive relaxation involving muscle tension and release.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

Correct Answer is B

Explanation

A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress.Which of the following instructions should the nurse give the client about using progressive relaxation?

Correct Answer is B

Explanation

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