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

 

A. Assist the client to perform range-of-motion exercises: Early range-of-motion exercises are not a priority immediately after near drowning, especially if the client may be hypothermic or unstable. Focus should be on stabilizing vital signs and preventing further complications first.

B. Replace wet clothing with warmed blankets: Removing wet clothing and providing external warming is critical to prevent hypothermia, which is a common and potentially life-threatening complication following immersion in cold water. This intervention helps stabilize body temperature and supports overall recovery.

C. Administer an antihypertensive medication: There is no indication to lower blood pressure in the acute management of near drowning unless the client is hypertensive and hemodynamically stable. Routine antihypertensive use is not part of initial care for immersion injuries.

D. Use an axillary thermometer to monitor the client's temperature: Axillary temperature measurements are less accurate in hypothermic clients and may underestimate core temperature. Core temperature assessment using rectal or esophageal methods is preferred for precise monitoring and management of hypothermia.

A. "You will not become fatigued when you use assistive devices.": Using assistive devices helps with mobility and independence but does not eliminate fatigue, especially after a CVA. Clients should be advised that energy conservation and pacing activities are still important.

B. "Plan to hire a home care aid to perform all of your ADLs.": Total reliance on a caregiver is unnecessary if the client can safely perform some ADLs with assistive devices. Encouraging independence supports rehabilitation and maintains function.

C. "Install grab bars in your shower to assist with your balance.": Grab bars provide stable support, reducing the risk of falls during bathing. This is a recommended safety modification for clients with impaired mobility or balance following a CVA.

D. "Place a towel in the shower to prevent slipping.": Placing a towel on the shower floor can increase the risk of tripping and falling. Safe modifications should include non-slip mats or grab bars rather than loose items.