You go to assess K.B. What additional data do you need to obtain because he has Graves' disease?
What will be an ideal response?
Ans: • Perform an in depth assessment of each of his presenting symptoms, including fatigue, insomnia,
chest pain, dyspnea, and palpitations.
• Explore whether he has experienced any difficulty concentrating, irritability, photophobia,
emotional lability, changes in appetite, changes in bowel habits, heat intolerance.
• Assess him for additional signs and symptoms of excess thyroid hormone: increased deep tendon
reflexes, tetany, tremor, ophthalmopathy (exophthalmos, periorbital edema, periorbital and
conjunctival inflammation, decreased extraocular muscle movement, corneal injury, blurred
vision, eye pain, photophobia, and diplopia), diaphoresis, and changes in hair, skin, or nails.
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A client who has been a resident of the long-term care facility for 6 months is complaining of shortness of breath. The nurse will perform a focused assessment that includes:
1. Auscultation of the hypogastric region. 2. Client's lifestyle. 3. Use of a pulse oximeter. 4. Shape of pupils.
The nurse is educating a patient who has recently been diagnosed with chronic obstructive pulmonary disease (COPD). The nurse explains how the gasses in the lungs move between the air spaces and the bloodstream
Which process is the nurse describing? a. Ventilation b. Diffusion c. Respiration d. Perfusion
A person who experienced a hemorrhagic cardiac vascular accident (CVA) to the left hemisphere would demonstrate which type of symptoms?
a. Language disturbances b. Poor impulse control c. Inappropriate affect d. Confabulation
A patient tells the nurse, "I dread going on after the divorce is final. I have no idea how I am going to manage financially or emotionally." The nurse realizes this patient is demonstrating which aspect of Caplan's stress and loss theory?
1. living without the assets and guidance 2. psychic pain 3. reduced problem-solving ability 4. emotional turmoil