The practical nurse (PN) is performing a focused assessment on a client with hyperthyroidism. To confirm the presence of exophthalmos, which action should the PN include in the assessment?
Palpating the client's neck gently.
Measuring the client's vital signs.
Compressing the client's pretibial area.
Observing the client's face and eyes.
The Correct Answer is D
Choice A reason: Palpating the client's neck gently is important in assessing thyroid function, as it can help detect the presence of thyroid enlargement or nodules. However, this action does not confirm the presence of exophthalmos, which is characterized by the protrusion of the eyeballs. Neck palpation is useful for evaluating thyroid size and consistency but does not provide information about eye-related symptoms.
Choice B reason: Measuring the client's vital signs, including heart rate, blood pressure, and temperature, is essential in monitoring the overall health and metabolic status of a client with hyperthyroidism. Hyperthyroidism can lead to increased heart rate, elevated blood pressure, and other systemic effects. However, measuring vital signs does not confirm the presence of exophthalmos. While vital signs provide important information about the client's condition, they do not address specific eye symptoms.
Choice C reason: Compressing the client's pretibial area is typically performed to assess for pretibial myxedema, which is another possible manifestation of hyperthyroidism, particularly in Graves' disease. Pretibial myxedema is characterized by thickening and swelling of the skin on the lower legs. However, this action does not confirm the presence of exophthalmos. It is important to assess for both pretibial myxedema and exophthalmos in clients with hyperthyroidism, but they require different examination techniques.
Choice D reason: Observing the client's face and eyes is the correct action to confirm the presence of exophthalmos. Exophthalmos is the abnormal protrusion of the eyeballs and is a common feature of Graves' disease, a type of hyperthyroidism. By carefully examining the client's face and eyes, the practical nurse can look for signs of eye protrusion, lid retraction, and other related symptoms. This focused assessment helps in identifying exophthalmos and determining the extent of the condition, which is essential for appropriate management and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Providing reassurance that hair loss is not usually permanent offers the client some comfort during a challenging time. Informing her that the color and texture may change when it grows back prepares her for potential differences in her hair's appearance post-chemotherapy. This response acknowledges the temporary nature of chemotherapy-induced hair loss while also being honest about the possibility of changes, which helps manage the client's expectations effectively.
Choice B reason: Stating that "people with cancer react differently to chemotherapy" is true, but it is not the most supportive or informative response. It may leave the client feeling uncertain and anxious about the outcome. Providing more specific information about hair regrowth, as in choice A, is more helpful in addressing the client's concerns and providing reassurance.
Choice C reason: While acknowledging that wigs are available is practical, focusing on the possibility that hair might not grow back can be disheartening for the client. It is important to offer hope and positivity where possible, and emphasizing the usual pattern of hair regrowth, as in choice A, is a more supportive approach. If the client does have concerns about wigs, this can be discussed separately.
Choice D reason: Indicating that hair regrowth depends on the amount of drug received is somewhat accurate but lacks the reassurance and positivity provided in choice A. It is important to give the client a clearer understanding that, in most cases, hair loss from chemotherapy is temporary, and hair will generally grow back. This helps alleviate some of the stress associated with the treatment.
Correct Answer is D
Explanation
Choice A reason: Initiating contact isolation precautions is not necessary for psoriasis. Psoriasis is not an infectious or contagious condition, so isolation is not required. The focus should be on managing symptoms and providing appropriate care to alleviate the client's discomfort.
Choice B reason: Explaining the need to keep the affected areas dry is not an appropriate action for psoriasis management. Psoriasis is characterized by dry, scaly patches of skin, and keeping the areas dry may worsen the condition. It is important to keep the skin moisturized and hydrated to reduce flaking and discomfort.
Choice C reason: Preparing the client for allergen testing is not relevant in this context. Psoriasis is an autoimmune condition, not an allergic reaction. Allergen testing is not typically used in the diagnosis or management of psoriasis. The focus should be on addressing factors that can exacerbate symptoms, such as stress, infections, and certain medications.
Choice D reason: Reviewing stress reduction strategies with the client is the most appropriate action. Stress is known to be a significant trigger for psoriasis flare-ups. By helping the client identify and implement stress reduction techniques, the PN can assist in managing the client's symptoms and improving their overall well-being. Techniques such as mindfulness, relaxation exercises, and counseling can be beneficial in reducing stress and minimizing psoriasis symptoms.
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