A 20-year-old client who has a clinical manifestation of ...

[elizabeth18]

A 20-year-old client who has a clinical manifestation of exophthalmos is in the clinic for follow-up care. Based on this finding, the nurse would plan a nursing diagnosis for this client of which of the following?
 
  1. Activity Intolerance
   2. Ineffective Coping
   3. Disturbed Body Image
   4. Risk for Injury

Question 2

Which of the following should the nurse include in the plan of care for a client with contact dermatitis?
 
  1. Provide instruction in the use of hot water and soap to bathe the body.
   2. Stress the importance of utilizing prescribed medication for the entire course.
   3. Teach the client the need to keep the skin dry.
   4. Provide instruction in washing clothes in bleach and hot water.

[blakcmamba]

Answer to Question 1

3. Disturbed Body Image

Rationale:
Exophthalmus is a clinical manifestation associated with hyperthyroidism and would be a problem for a young client. The nurse would plan to assess self-esteem and make appropriate referrals. Activity intolerance and risk for injury are not particular to this medical diagnosis. The client's ability to cope could be an issue, but it would probably stem from the disturbed body image.

Answer to Question 2

2. Stress the importance of utilizing prescribed medications for the entire course.

Rationale:
Clients should be instructed to use prescribed medications for the entire course. Stopping the treatment too soon could cause rebound dermatitis. The client should be instructed to use tepid water and mild soap to bathe. The skin should be kept lubricated to prevent dryness and itching. Clothing should be washed in mild soap and rinsed an extra time to remove all soap.