While performing an assessment of the integument system, the ...

[ghost!]

While performing an assessment of the integument system, the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated. What term would the nurse use to document this finding?
 
  1. Erythema
  2. Cyanosis
  3. Exophthalmos
  4. Normocephalic

Question 2

The nurse is preparing for morning rounds. What may not be delegated to the nursing assistant?
 
  1. Vital signs
  2. Fill water pitchers
  3. Skull and face assessment
  4. Ambulate surgical clients

[tjayeee]

Answer to Question 1

Correct Answer: 3
Rationale 1: Erythema is a term used to describe redness.
Rationale 2: Cyanosis is a term used to describe a bluish cast to the skin, nails, or mucous membranes.
Rationale 3: Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression.
Rationale 4: Normocephalic is a term used to describe a normal sized head.

Answer to Question 2

Correct Answer: 3
Rationale 1: Vital signs can appropriately be delegated to unlicensed assistive personnel.
Rationale 2: Filling water pitchers can be appropriately delegated to unlicensed assistive personnel.
Rationale 3: Assessment of the skull and face may not be delegated to unlicensed assistive personnel.
Rationale 4: Ambulating surgical clients can be appropriately delegated to unlicensed assistive personnel.