A nurse is caring for a client in a clinic. Nurses' Notes.
0900: A16-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 survivor and witnessed their family's deaths.
0910: Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorm, but the client admits that they have always been afraid of thunderstorms. Client admits 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 do attend school regularly and are on the honor roll.
Vital Signs. 0915: Temperature 36.7° C (98° F), BP 122/80 mm Hg, Respiratory rate 20/min, Heart rate 99/min.
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.
1. BP 122/80 mmHg.
2. Heart rate 99/min.
3. Startles easy during thunderstorm.
4. Client experiences nightmares.
5. Witnessing their family's death.
6. Caregiver reporting client acting differently than usual.
7. Attends school regularly.
8. Smoking marijuana to clear their mind.