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

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

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 ×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, fat, normoactive bowel sounds in all four quad 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. Exophthalmus noted, goiter visualized on neck. Client’s partner reports that the client is imitable and anxious lately.

A.

a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well

B.

Reports last menstrual period was 3 months ago

C.

Exophthalmus noted, goiter visualized on neck. Client’s partner reports that the client is imitable and anxious lately

D.

Abdomen soft, fat, normoactive bowel sounds in all four quad states

E.

No abnormal heart sounds heard

Answer and Explanation

The Correct Answer is ["A","B","C"]

  • 3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and difficulty sleeping: These symptoms are classic for hyperthyroidism and suggest worsening metabolic imbalance. They require follow-up because untreated hyperthyroidism can lead to serious complications like thyroid storm.
  • Reports last menstrual period was 3 months ago: Amenorrhea or menstrual irregularities are common in hyperthyroidism due to hormonal disruption. This finding supports the diagnosis and needs follow-up for endocrine and reproductive health management.
  • Exophthalmos noted: Exophthalmos, or bulging eyes, is associated with Graves' disease and indicates autoimmune involvement affecting the orbital tissues. It can lead to complications like corneal ulceration or vision loss if severe and thus requires ophthalmologic evaluation.
  • Goiter visualized on neck: A visible goiter reflects thyroid gland enlargement, often due to hyperstimulation from excess thyroid hormones. It requires ongoing monitoring to assess for airway compromise, dysphagia, or further gland enlargement.
  • Client’s partner reports irritability and anxiety: Behavioral and mood changes like irritability and anxiety are manifestations of hyperthyroidism affecting neurological function. Persistent symptoms can impair quality of life and must be addressed as part of comprehensive treatment planning.


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Related Questions

Correct Answer is B

Explanation

A. Anuria: Anuria, or the absence of urine output, indicates severe dehydration or acute renal failure rather than moderate dehydration. Moderate dehydration usually presents with decreased but not absent urine output, as the body still tries to conserve fluids.

B. A 7% weight loss from baseline: A weight loss of 6% to 9% of body weight is consistent with moderate dehydration in infants and children. This measurable sign is a critical and objective indicator used to assess the severity of dehydration, particularly following prolonged vomiting or diarrhea.

C. Hyperpnea: Hyperpnea, or abnormally deep and rapid breathing, can be seen in cases of severe dehydration or metabolic acidosis. It is not a classic finding of moderate dehydration, where respiratory patterns are usually normal or only mildly affected.

D. Lethargy: Lethargy typically suggests severe dehydration rather than moderate. In moderate dehydration, the infant may be irritable or thirsty but usually maintains normal mental status without profound decreases in responsiveness or alertness.

Correct Answer is D

Explanation

A. "I will use a sitz bath at least once a day.": Sitz baths should be used more frequently, typically several times a day, to promote perineal healing, relieve discomfort, and reduce swelling after an episiotomy. Limiting it to once daily may not provide adequate relief or hygiene support.

B. "I will check the amount of bleeding with every other pad change": The amount of lochia (postpartum bleeding) should be checked with every pad change, not every other. Monitoring bleeding closely helps detect signs of hemorrhage or infection early, ensuring prompt intervention if abnormalities are found.

C. "I will wash my perineum with mild soap and warm water every other day.": Perineal hygiene should be performed daily, and often multiple times a day, especially after urination or bowel movements. Washing every other day is insufficient and could increase the risk of infection at the episiotomy site.

D. "I will change my pad at least three times a day": Changing the perineal pad at least three times daily, or more often as needed, maintains cleanliness, helps prevent infection, and allows for regular monitoring of lochia and healing. This statement demonstrates good understanding of postpartum perineal care.

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