A nurse is collecting data from a client who has Graves' disease.
Which of the following signs should the nurse identify as an indication that the client is experiencing exophthalmos?

Choice A rationale

Eggs are high in sulfur-containing amino acids such as methionine, which bacteria in the gut break down to produce hydrogen sulfide gas. This gas significantly contributes to odor in individuals with colostomies. Thus, eggs are not recommended for controlling odor.

Choice B rationale

Asparagus contains a compound known as asparagusic acid, which breaks down into sulfur-containing byproducts during digestion. These compounds are excreted and can lead to malodorous output in colostomy patients, making asparagus less suitable for controlling odor.

Choice C rationale

Potatoes are low in sulfur-containing compounds and high in fiber, which promotes healthy digestion and decreases gas formation. They are considered a low-odor food, making them ideal for inclusion in the diet of colostomy patients aiming to minimize odor.

Choice D rationale

Dried beans are rich in complex carbohydrates such as raffinose and stachyose that ferment in the large intestine. This fermentation process generates excessive gas, leading to increased odor in colostomy patients. Therefore, dried beans are not advisable.

Choice A rationale

Instilling saline into the tubing is not recommended as it increases infection risks and does not clear secretions effectively. It is contraindicated in tracheostomy care and can harm the patient’s respiratory system.

Choice B rationale

Checking the cuff pressure is essential to prevent complications like tracheal injury or air leaks. However, it does not directly alleviate restlessness or crackles in the lungs caused by secretions.

Choice C rationale

Performing suctioning removes secretions from the tracheostomy tube and airways, improving oxygenation and reducing lung crackles. It is the most effective immediate intervention for this scenario.

Choice D rationale

Increasing humidification prevents secretion thickening but does not address accumulated secretions already causing crackles and respiratory distress.