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

Rating pain on a scale from 0 to 10 assesses pain intensity rather than quality. Intensity quantifies the severity of pain but does not describe its characteristics, such as sharpness, dullness, or burning, which are essential for understanding the pain's nature and underlying etiology.

Choice B rationale

Asking about pain presence or absence identifies whether the client is experiencing pain but provides no information about its quality. This question is insufficient for determining pain characteristics, which require descriptive responses to guide appropriate intervention and diagnosis.

Choice C rationale

Asking the client what their pain feels like elicits a description of pain quality. Quality includes terms such as throbbing, sharp, or burning, which help identify the type of pain and its potential causes, differentiating between nociceptive, neuropathic, or referred pain.

Choice D rationale

Comparing current pain to previous pain assesses pain trends and patterns but does not address the quality of the pain. This question is more suited for evaluating treatment effectiveness over time rather than diagnosing the nature of the pain.

Choice A rationale

Monitoring for fever is essential as fever may indicate infection, a complication of PICC line use. Early detection of infection is crucial since central lines increase susceptibility to bloodstream infections.

Choice B rationale

Pulling the dressing away from the insertion site disrupts the sterile barrier, increasing the risk of infection. Proper dressing techniques are necessary to maintain sterility and minimize complications.

Choice C rationale

Wearing an arm immobilizer is not standard PICC care and may restrict mobility unnecessarily. Instead, education on proper handling and precautions is emphasized to prevent device dislodgement.

Choice D rationale

Keeping the device dry is imperative, as water exposure compromises the integrity of the dressing and insertion site sterility. Clients should cover the PICC line area during showers to prevent wetting.