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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 B

Explanation

Rationale:

A. Direct questions to the interpreter: Communication should be directed to the client, not the interpreter. Speaking directly to the client fosters rapport and respects their autonomy, while the interpreter facilitates understanding.

B. Ask the client for regular feedback: Checking in frequently with the client ensures they understand the information being conveyed. This helps clarify misunderstandings and confirms effective communication through the interpreter.

C. Incorporate acronyms into client teaching: Using acronyms can confuse clients, especially those with limited English proficiency or unfamiliarity with medical terminology. Clear, simple language without jargon is preferred.

D. Ask the client's family member to interpret: Family members may lack medical terminology knowledge, may filter information, or breach confidentiality. Professional interpreters provide more accurate and unbiased communication.

A. "We've seen steady improvement in other clients who are depressed." B. "Tell me what you know about depression," C. "No one really knows the answer to that question." D. "The important thing is that he gets better, not how long it takes."

Correct Answer is B

Explanation

Rationale:

A. "We've seen steady improvement in other clients who are depressed.": While this may sound reassuring, it provides generalized information that may create unrealistic expectations. It does not address the partner’s specific concerns or open up a dialogue for emotional support or understanding.

B. "Tell me what you know about depression,": This response encourages open communication and assesses the partner's understanding of the condition. It allows the nurse to provide accurate, individualized information and emotional support based on what the partner already knows or believes.

C. "No one really knows the answer to that question.": Though factually true, this statement may seem dismissive or lacking empathy. It does not invite discussion or support the emotional needs of the partner, who is likely feeling uncertain or overwhelmed.

D. "The important thing is that he gets better, not how long it takes.": This response minimizes the partner’s valid concern about recovery time. It may come across as invalidating and does not provide helpful or therapeutic communication.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who needs an interpreter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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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.