Author Question: The nurse is providing care for a young adult client with exophthalmos. Which nursing diagnosis ... (Read 121 times)

tiara099 · **on:** Jun 25, 2018

The nurse is providing care for a young adult client with exophthalmos. Which nursing diagnosis would be the most appropriate for this client?

A) Disturbed Body Image
B) Ineffective Coping
C) Risk for Injury
D) Activity Intolerance

Question 2

A client with Parkinson disease (PD) states to the nurse, It is 1950 and I am late for work. What action should the nurse take at this time?

A) Orient the client, provide a calendar, and place a clock in the room.
B) Ask the client what life is like in 1950.
C) Medicate for confusion.
D) Apply restraints so the client will not attempt to get out of bed to go to work.

mk6555 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: A

Exophthalmos is a clinical manifestation associated with hyperthyroidism and may 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

Answer: A

Clients with PD may demonstrate confusion and disorientation. This is what the client is demonstrating. The nurse should orient the client, provide a calendar, and place a clock in the room to assist with ongoing orientation. The nurse should not medicate the client for confusion or apply restraints. The nurse should not feed into the confusion by asking what life is like in 1950.