A nurse is assessing a client who has Graves’ disease. The nurse should expect which of the following laboratory results?

Choice A reason: Stretch marks, also known as striae, are not specific to ascites. They can occur due to rapid weight gain or loss, pregnancy, or other conditions that cause the skin to stretch. While they may be present in individuals with ascites due to rapid abdominal expansion, they are not a primary clinical manifestation of ascites.

Choice B reason: Foul-smelling breath, or halitosis, is not a typical symptom of ascites. It can be associated with various conditions, including poor oral hygiene, gastrointestinal disorders, or liver disease, but it is not a direct indicator of ascites.

Choice C reason: Increased abdominal girth is a primary clinical manifestation of ascites. Ascites is characterized by the accumulation of fluid in the peritoneal cavity, leading to noticeable abdominal distension. This symptom is often accompanied by a feeling of fullness or bloating.

Choice D reason: Visible distended veins, particularly around the abdomen, can be a sign of ascites. This occurs due to increased pressure in the abdominal veins as a result of fluid accumulation. The veins become more prominent and visible under the skin.

Choice E reason: Rapid weight gain is another key indicator of ascites. The accumulation of fluid in the abdomen leads to a significant increase in body weight over a short period. This rapid weight gain is often one of the first signs that prompts further investigation for ascites.

Intervention: Validate that informed consent has been given by the client.

Reason: Before any invasive procedure, it is crucial to ensure that the client has given informed consent. This means the client understands the procedure, its risks, benefits, and any potential complications. Validating informed consent is a legal and ethical requirement that ensures the client is making an informed decision about their care12.

Assessment: The trachea is shifted away from the midline of the neck.

Reason: A tracheal shift is a critical finding that warrants immediate action. It can indicate a tension pneumothorax, which is a life-threatening condition where air accumulates in the pleural space and causes the lung to collapse. This shift can compromise respiratory function and requires urgent intervention34.

Choice B: Pulse oximetry is 93% on 2 L of oxygen.

Reason: While a pulse oximetry reading of 93% on 2 liters of oxygen is slightly below the normal range (95-100%), it is not immediately life-threatening. However, it does indicate that the client may need further evaluation and monitoring to ensure adequate oxygenation.

Choice C: The client rates pain as 8/10 at the site of the procedure.

Reason: Pain management is important, but an 8/10 pain rating at the procedure site, while significant, does not require immediate action compared to a tracheal shift. Pain can be managed with appropriate analgesics as ordered by the physician.

Choice D: Request an order for pain medication.

Reason: Requesting an order for pain medication is a necessary intervention for managing the client’s pain, but it is not as urgent as addressing a tracheal shift. Pain management should be part of the overall care plan.

Choice E: Measure oxygen saturation before and after a 12-minute walk.

Reason: Measuring oxygen saturation before and after a 12-minute walk is a useful assessment to evaluate the client’s respiratory function and endurance. However, it is not an immediate priority compared to ensuring informed consent and addressing critical findings.

Choice F: Explain the procedure in detail to the client and the family.

Reason: Explaining the procedure in detail to the client and their family is essential for informed consent and reducing anxiety. It ensures that the client understands what to expect and can make an informed decision about their care.

Choice G: Assist the client to the bathroom.

Reason: Assisting the client to the bathroom is a routine nursing intervention that ensures the client’s comfort and dignity. However, it is not a priority compared to addressing critical findings and ensuring informed consent.

Choice H: Discuss all possible complications with the client.

Reason: Discussing all possible complications with the client is part of the informed consent process. It ensures that the client is aware of potential risks and can make an informed decision about their care.

Choice I: A small amount of drainage from the site is noted.

Reason: Noting a small amount of drainage from the site is an important assessment, but it is not as urgent as addressing a tracheal shift. The drainage should be monitored and documented, and any significant changes should be reported to the physician.