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Select the 4 findings that require follow-up.

A.

Witnessing their family's death

B.

Caregiver reporting client acting differently than usual

C.

Attends school regularly

D.

Startles easy during thunderstorm

E.

Heart rate 99/min

F.

BP 122/80 mmHg

G.

Smoking marijuana to clear their mind

H.

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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Related Questions

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

Explanation

Rationale:

• Obtain daily weights: Daily weights are used to monitor fluid balance in conditions like preeclampsia or heart failure. In this acute preterm labor scenario, the priority is monitoring fetal well-being and uterine activity, not long-term fluid shifts.

• Administer terbutaline: Terbutaline is a tocolytic medication used to suppress preterm labor by relaxing uterine smooth muscle. Given the client’s regular, strong contractions at 33 weeks with cervical changes, terbutaline may be prescribed to delay labor and allow fetal maturation.

• Administer oxytocin: Oxytocin stimulates uterine contractions and is used to induce or augment labor. In a client experiencing preterm labor at 33 weeks, oxytocin is contraindicated because it could worsen labor progression and increase risk of preterm birth.

• Administer betamethasone: Betamethasone is a corticosteroid administered to accelerate fetal lung maturity when preterm birth is imminent. Since the client is 33 weeks gestation and showing signs of preterm labor, administration is anticipated to reduce neonatal respiratory complications.

• Maintain modified bed rest with bathroom privileges: Modified bed rest can help reduce uterine stimulation, conserve energy, and support uteroplacental perfusion in clients experiencing preterm labor. Limiting physical activity is a standard intervention for preterm labor management.

Correct Answer is B

Explanation

A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.

B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.

C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.

D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.

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