A nurse is contributing to the discharge plan for a client who had a skin graft of the upper extremities following a full-thickness burn. Which of the following instructions should the nurse include in the discharge plan?

• Report of menstrual cycle: Amenorrhea or infrequent menstrual cycles commonly occur in hyperthyroidism due to disruption of the hypothalamic-pituitary-ovarian axis. Excess thyroid hormones alter estrogen metabolism and ovulation patterns. Hypothyroidism typically causes menorrhagia (heavy periods).

• Weight change: Unplanned weight loss despite a good appetite is a hallmark feature of hyperthyroidism. Increased thyroid hormone levels accelerate metabolism, leading to increased energy expenditure. The client’s three-month history of weight loss strongly reflects this hypermetabolic state. Hypothyroidism more commonly causes weight gain.

• Skin condition: Warm, moist skin is characteristic of hyperthyroidism due to increased heat production and peripheral vasodilation. Excess thyroid hormone raises basal metabolic rate, resulting in sweating and warmth. This finding contrasts with the dry, cool skin typically seen in hypothyroidism.

• Neck exam: The presence of a goiter indicates thyroid gland enlargement, which is common in Graves’ disease. A goiter (enlarged thyroid) can be present in both conditions. In hyperthyroidism, it's often due to overstimulation (Graves'); in hypothyroidism, it can be due to a lack of iodine or compensatory growth (Hashimoto's).

• Laboratory results: Elevated T3 and free T4 levels confirm excess circulating thyroid hormones. The increased TSI level indicates an autoimmune process stimulating the thyroid gland. These laboratory values are diagnostic for Graves’ disease, a form of hyperthyroidism. Hypothyroidism would show low T3 and T4 levels.

• Eye appearance: Exophthalmos is a classic manifestation of Graves’ disease and results from autoimmune inflammation of orbital tissues. It is not seen in hypothyroidism. This finding directly points to hyperthyroidism with autoimmune involvement. The eye changes further reinforce the diagnosis.

A. Instruct the AP to report back once the task is complete: Simply having the AP report completion does not verify whether the procedure was performed correctly or safely. Observation or demonstration is necessary to ensure competency and client safety.

B. Request the AP to provide a return demonstration of the task: Having the AP perform a return demonstration allows the nurse to directly observe technique, adherence to infection control, and correct administration. This method ensures the AP can safely perform the gastrostomy feeding and allows immediate correction of errors.

C. Tell the AP to list the steps of the task: Verbalizing the steps demonstrates knowledge but does not confirm the AP’s ability to safely perform the procedure. Skill proficiency requires hands-on demonstration rather than only theoretical recall.

D. Ask the family if the AP performed the task correctly: Family feedback may be subjective and unreliable, especially if the family is not trained to recognize correct technique or safety issues. It does not replace direct observation by the nurse.