Select the 4 findings that require follow-up.
Witnessing their family's death
Caregiver reporting client acting differently than usual
Attends school regularly
Startles easy during thunderstorm
Heart rate 99/min
BP 122/80 mmHg
Smoking marijuana to clear their mind
Client experiences nightmares
Correct Answer : A,B,D,H
Based on the information provided, the following findings require immediate follow-up:
A. Witnessing their family's death: The client witnessing their family's death during the tornado is a traumatic event that may have significant psychological implications. This finding requires immediate attention and further assessment to address the client's emotional well-being.
B. Caregiver reporting client acting differently than usual: The caregiver's concern about the client "not being themselves lately" is important and may indicate changes in the client's behavior or mental state. This requires immediate follow-up to explore the reasons behind the change in behavior.
D. Startles easily during thunderstorm: The client's heightened startle response during thunderstorms may be indicative of increased anxiety or trauma-related symptoms. This finding requires further evaluation and intervention.
G. Smoking marijuana to clear their mind: The client's use of marijuana to cope with their emotions and thoughts indicates maladaptive coping mechanisms. This finding requires immediate follow-up to address substance use and provide appropriate support.
H. Client experiences nightmares: The client's nightmares are likely related to the traumatic event they witnessed, and they may be experiencing symptoms of post-traumatic stress disorder (PTSD). This finding requires immediate attention and assessment to provide appropriate mental health support.
The other findings mentioned (C, E, F) are not concerning based on the information provided and do not require immediate follow-up. However, they may still be relevant for the client's overall assessment and care plan. The nurse should prioritize addressing the immediate mental health and emotional needs of the client, given the recent traumatic experience they went through.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Incorrect. Rounding the edges of toenails can lead to ingrown toenails, which should be avoided.
B. Incorrect. Soaking feet twice daily can lead to dry skin and potentially increase the risk of infection, so it's not recommended.
C. Incorrect. Using moisturizing lotion between the toes can also increase the risk of moisture-related skin issues. It's better to keep the area between the toes dry.
D. Correct. Wearing clean cotton socks helps maintain proper foot hygiene and prevents moisture accumulation, reducing the risk of fungal infections.
Correct Answer is B
Explanation
A. Biological response modifiers are medications used to treat autoimmune diseases like rheumatoid arthritis, not to prevent infection.
B. Taking a hot shower in the morningcan help decrease stiffness and improve joint mobility for people with rheumatoid arthritis.
C. Clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis. It is better to pace activities throughout the day and take frequent breaks to rest the joints.
D. Cold packs can help reduce inflammation and pain, but they should be applied with a cloth barrier to protect the skin from direct contact.
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