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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 A

Explanation

Rationale:

A. "I feel that soon everything will be ok.": This is a covert statement because it sounds hopeful but may actually reflect a decision to end one’s life. Sudden calmness or vague optimism in someone with a history of major depressive disorder can indicate suicidal planning and should prompt immediate follow-up.

B. "I just cannot take this anymore.": This is an overt expression of emotional distress and hopelessness. While serious, it clearly communicates the client's feelings and is more direct than covert.

C. "My family would be better off if I was dead.": This is an overt suicidal statement suggesting that the client believes their death would benefit others. It requires immediate attention and suicide risk assessment.

D. "I do not want to be here anymore.": This is another overt expression that directly indicates a desire to no longer live or be present. It reflects suicidal ideation and needs urgent intervention but is not considered covert.

A. "What coping methods help you when you feel bad?" B. "Do you have thoughts of suicide?" C. "Tell me why you hurt yourself." D. "Who can we call to support you?"

Correct Answer is B

Explanation

Rationale:

A. "What coping methods help you when you feel bad?": While assessing coping mechanisms is important for long-term care planning, it does not immediately address the client's current risk for self-harm or suicide. This question is more appropriate after ensuring the client's safety.

B. "Do you have thoughts of suicide?": Determining if the client has suicidal ideation is the priority in this situation. Clients who self-harm may be at high risk for suicide, and direct questioning helps assess intent, plan, and urgency, which is crucial for ensuring immediate safety.

C. "Tell me why you hurt yourself.": Exploring the reasons behind self-injury can be valuable later during therapy or assessment, but it is not the first priority. The nurse must first evaluate the client’s current mental state and risk for further harm before exploring motives.

D. "Who can we call to support you?": Identifying a support system is important for discharge planning and ongoing therapy, but it does not address the immediate concern of suicide risk. Ensuring the client's current safety takes precedence over external support at the time of admission.

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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.