When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

Choice A Reason:
Appears confused and depressed is incorrect. This option includes subjective interpretations ("confused" and "depressed") that may not accurately reflect the observed behavior. It's important to avoid subjective assessments and stick to objective descriptions of the client's behavior and mental status.
Choice B Reason:
Demonstrates signs of early dementia is incorrect. This option jumps to a diagnostic label ("early dementia") based on the observed behavior, which is not appropriate without further assessment and evaluation by a healthcare provider specializing in geriatric care or neurology. It's crucial to avoid diagnosing conditions based solely on observations without proper evaluation.
Choice C Reason:
While the client is ambulatory, the term "disoriented to place" is an assumption that has not been explicitly confirmed through an assessment. The documentation should be based on observable facts rather than assumptions.
Choice D Reason:
This statement is accurate, objective, and based on observable behaviors. "Wandering behavior" describes the client's aimless walking, and "flat affect" refers to the blank expression. This documentation does not make assumptions about the client's mental state beyond what is directly observable.

Choice A Reason:
Recently had dental surgery is incorrect. Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising (ecchymosis) around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities. Therefore, while dental surgery may be relevant to the client's overall health history, it is less likely to directly relate to the widespread ecchymosis observed.
Choice B Reason:
Takes an oral anticoagulant is correct. Taking an oral anticoagulant medication increases the risk of bleeding, which can manifest as ecchymosis (bruising) on the skin. Anticoagulants such as warfarin or aspirin can interfere with the blood's ability to clot, leading to bleeding into the skin and subsequent ecchymosis. Therefore, this information is particularly important to follow up on as it may directly contribute to the observed ecchymosis.
Choice C Reason:
Adheres to a gluten-free diet is incorrect. Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. While celiac disease can be associated with certain skin conditions, ecchymosis is not a typical manifestation of gluten intolerance. Therefore, while this information may be relevant to the client's overall health, it is less likely to directly explain the observed ecchymosis.
Choice D Reason:
Works in a day care center is incorrect. Working in a day care center may involve activities that could result in minor injuries or bruises, but it is less likely to explain widespread ecchymosis observed on the trunk and extremities. While accidental injuries are possible in a daycare setting, they would typically be localized and not widespread. Therefore, while this information may be relevant to the client's occupation and risk of injury, it is less likely to directly relate to the observed ecchymosis.