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A nurse is assisting with the care of a client in a provider's clinic.

Exhibits
Select the findings that require follow-up.

The client presents to clinic reporting a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well.

Oriented x 4. Answers questions appropriately, follows simple commands. Heart rate regular, S1 S2 auscultated. No abnormal heart sounds heard. Respiration even and unlabored. Lung sounds clear to auscultation. Abdomen soft, flat, normoactive bowel sounds in all four quadrants. Client states, "appetite is good" and stools are soft and brown.

Reports voiding without difficulty, clear yellow urine.

Reports last menstrual period was 3 months ago.

Skin is warm and moist. Exophthalmos noted, goiter visualized on neck.

Client's partner reports that the client is irritable and anxious lately.

Answer and Explanation

Correct Answer : A,D,E,F

Rationale:

• 3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and insomnia: These symptoms are consistent with hypermetabolic activity seen in hyperthyroidism, particularly Graves’ disease, and require follow-up and management to prevent complications like thyroid storm.

• Last menstrual period was 3 months ago: Amenorrhea can occur due to hormonal imbalance caused by elevated thyroid hormones. This finding indicates endocrine dysfunction and should be investigated further.

• Skin is warm and moist. Exophthalmos noted, goiter visualized on neck: These are classic physical signs of Graves’ disease, an autoimmune hyperthyroid condition. The exophthalmos (protruding eyes) and goiter (thyroid enlargement) are abnormal and require follow-up.

• Client's partner reports that the client is irritable and anxious lately: Mood changes, such as irritability and anxiety, are common in hyperthyroidism and may affect the client’s quality of life and safety. This finding warrants further psychological and endocrine evaluation.

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Correct Answer is C

Explanation

Rationale:

A. "I will wait 1 hour after getting up in the morning to have breakfast.": Delaying breakfast may worsen nausea, as symptoms of hyperemesis gravidarum are often worse in the morning. It is recommended to eat a small, dry carbohydrate-rich snack, such as crackers, soon after waking.

B. "I will try to eat balanced meals instead of only foods that appeal to my taste.": While balanced meals are ideal, during hyperemesis gravidarum, the priority is tolerating any nutrition. Clients are encouraged to eat whatever foods they can tolerate, as nutritional intake is often severely limited.

C. “I will eat or drink something every 2 to 3 hours throughout the day": Eating or drinking small amounts frequently helps prevent an empty stomach, which can trigger or worsen nausea and vomiting. This approach improves tolerance and supports hydration and nutrition.

D. “I will eat a low protein snack 30 minutes before going to bed each night.": Protein-rich snacks, not low-protein ones, are better for stabilizing blood glucose levels overnight and may help reduce morning nausea. A high-protein snack before bed is more appropriate.

A. Examine the client's nail beds. B. Place the client in the supine position. C. Encourage client to perform deep breathing exercises. D. Prepare to administer oxygen via Venturi face mask. E. Add a humidifier to the oxygen device.

Correct Answer is ["A","C","D"]

Explanation

Rationale:

• Examine the client's nail beds: Assessing nail beds for cyanosis provides visual clues of hypoxia. This is a noninvasive, rapid method to evaluate tissue perfusion and oxygenation. The client's saturations are borderline low despite increasing oxygen.

• Place the client in the supine position: The supine position can reduce lung expansion and worsen hypoxia, especially after sedation. Elevating the head of the bed promotes lung expansion and better diaphragmatic movement.

• Encourage client to perform deep breathing exercises: Deep breathing helps expand alveoli and improves oxygen exchange. It may reduce the need for higher oxygen delivery if the hypoxia is due to shallow respirations after sedation.

• Prepare to administer oxygen via Venturi face mask: The client's O₂ saturation is dropping despite nasal cannula at 5 L/min. A Venturi mask delivers a more precise and consistent oxygen concentration, making it appropriate here.

• Add a humidifier to the oxygen device: Humidification is generally needed for oxygen above 4 L/min over long durations. This client has only been on oxygen for a short time post-procedure, so humidification is not urgently required.

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A nurse is assisting with the care of a client in a provider's clinic. Exhibits Select the findings that require follow-up.

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A nurse is assisting with the care of a client in a provider's clinic.

Exhibits
Select the findings that require follow-up.