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?
Bulging of the eyes.
Sunken appearance of the eyes.
Swelling of the eyelids.
Redness and watering of the eyes.
The Correct Answer is A
Choice A rationale
Exophthalmos is characterized by abnormal protrusion or bulging of the eyes due to retro-orbital tissue swelling and inflammation associated with Graves’ disease. This condition is a hallmark symptom of Graves’ ophthalmopathy.
Choice B rationale
Sunken eyes are not indicative of exophthalmos and are typically associated with dehydration or aging, rather than retro-orbital tissue changes as seen in Graves’ disease.
Choice C rationale
Eyelid swelling might occur in various conditions, such as allergies or infections, but it does not specifically point to exophthalmos or Graves’ disease-related complications.
Choice D rationale
Redness and watering of the eyes are non-specific symptoms that could occur in conjunctivitis or dry eye syndrome but do not define exophthalmos uniquely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Red scaly patches with raised edges are characteristic of skin conditions like psoriasis or eczema, not venous stasis ulcers, which result from chronic venous insufficiency.
Choice B rationale
Round lesions with irregular borders are commonly seen in arterial ulcers. They result from ischemia rather than chronic venous insufficiency and differ in appearance from venous stasis ulcers.
Choice C rationale
Wounds with darkened pigmentation and drainage are hallmarks of venous stasis ulcers. Chronic venous insufficiency causes venous hypertension, leading to hemosiderin deposition, pigmentation, and wound development.
Choice D rationale
Circular areas with pale centers are associated with conditions like erythema multiforme or arterial issues, not with venous stasis ulcers arising from venous insufficiency.
Correct Answer is B
Explanation
Choice A rationale
Squeezing each testicle between the thumb and forefinger is incorrect for testicular self-examination. This method could cause discomfort and does not allow proper palpation of the testicle surface for detecting abnormalities.
Choice B rationale
Performing the examination just after a warm bath or shower is recommended because warmth relaxes the scrotum, making it easier to feel for lumps or changes in the testicular tissue. This improves examination accuracy.
Choice C rationale
Beginning testicular self-examination at 30 years of age is incorrect. Guidelines suggest that self-examination should begin in adolescence or early adulthood to identify testicular cancer early, as it often affects younger men.
Choice D rationale
Completing the examination once per week is excessive and could lead to unnecessary anxiety. Monthly self-examinations are typically recommended to monitor for changes or abnormalities over time. .
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