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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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Incorrect. Referring the adolescent to a mental health clinic is not the primary action to address her concerns about affording and caring for her baby.

B. Incorrect. Advising adoption might not be appropriate if the adolescent wants to explore options for keeping and caring for her baby.

C. Incorrect. Contacting the adolescent's parent for assistance may not be feasible or appropriate if the adolescent's situation does not allow for parental involvement.

D. Correct. Assisting the adolescent in applying for Medicaid is a practical step to help her access financial assistance for her pregnancy-related care and the care of her baby.

A. "You can receive the immunization for influenza at any time during your pregnancy." B. "The hepatitis B immunization should not be obtained until after you finish breastfeeding." C. "You can receive the rubella immunization during the third trimester of pregnancy." D. "The immunization for varicella should be given at least 1 month prior to delivery."

Correct Answer is A

Explanation

A. Correct. Influenza immunization is recommended for pregnant individuals, and it can be given at any time during pregnancy, especially during flu season.
B. Incorrect. The hepatitis B immunization is safe during pregnancy and can be administered if indicated, regardless of breastfeeding status.
C. Incorrect. Rubella immunization is not recommended during pregnancy due to potential risks to the fetus. It should be given prior to pregnancy or after delivery.
D. Incorrect. Varicella immunization is also not recommended during pregnancy due to potential risks. It should be administered before pregnancy or after delivery if needed.

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Select the 4 findings that require follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

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A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?

A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require an dropdown as evidenced by the client's dropdown.

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?