While performing an assessment of the integument system, the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated. What term would the nurse use to document this finding?
1. Erythema
2. Cyanosis
3. Exophthalmos
4. Normocephalic
Correct Answer: 3
Rationale 1: Erythema is a term used to describe redness.
Rationale 2: Cyanosis is a term used to describe a bluish cast to the skin, nails, or mucous membranes.
Rationale 3: Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression.
Rationale 4: Normocephalic is a term used to describe a normal sized head.
You might also like to view...
A group has two more sessions before it ends. One member who previously has been vocal and has shown much progress has grown silent. What explanation most likely underlies his current silence?
a. He has said what is on his mind and now has nothing more to offer. b. He wants to give quieter members a chance to talk in the time remaining. c. Quiet members are dominating now in order to talk more before group ends. d. He is having trouble dealing with his feelings about the group's ending.
The nurse is assessing a client who states that exercise is a high priority and who recently changed jobs because the previous job was taking away from time for several extended workouts each day
What would be the expected diagnosis for this client? A) Obesity B) Anorexia nervosa C) Bulimia nervosa D) Binge eating
A woman comes into a psychiatric office and tells a nurse, "You're new here—I don't know you. How did you get hired here, and what are you up to?" Which diagnosis should the nurse anticipate?
A) Obsessive–compulsive personality disorder B) Schizotypal personality disorder C) Histrionic personality disorder D) Paranoid personality disorder
An elderly patient is covered under Medicare. She is scheduled for discharge and tells the nursing student that several therapists will come to her home to help her regain functional abilities
The patient then asks, "Why can't I just stay in the hospital and receive this type of care?" What is the nursing student's best response? a. "You should be able to stay in the hospital. I will ask the nurse to call your doctor." b. "Once you have reached your reimbursable length of stay and your condition is stable, it is more cost effective to provide you with home healthcare." c. "Medicare is a type of managed care, which mean that you are only allowed to stay in the hospital for a certain number of days before being discharged, regardless of your condition." d. "You should be glad to be in your own home. You will recover in no time."