Medical Surgical Thyroid #1

Question

In planning the care for a client with Graves Disease, which nursing diagnosis will the nurse select?

Answers

  1. Alteration in Nutrition: More than body requirements related to hypometabolic state.
    • Rationale:

      This answer is not correct because in Graves disease, the client has a hypermetabolic state, which causes the client to lose weight rather than gain or have more than body requirements. Exophthalmos is a cardinal sign of Graves’ disease. This bulging of the eye anteriorly from the orbit makes it where the eye lid does not shut completely over the eye. This can cause extreme dryness which can lead to corneal abrasions.

  2. Impaired gas exchange related to inability to perform activities of daily living without oxygen.
    • Rationale:

      This answer is not correct because when a client has Graves’ disease, impaired gas exchange related to inability to perform activities of daily living without oxygen is not a usual problem. On the other hand, exophthalmos is a cardinal sign of Graves’ disease. This bulging of the eye anteriorly from the orbit makes it where the eye lid does not shut completely over the eye. This can cause extreme dryness which can lead to corneal abrasions.

  3. Self Care deficit: Actual related to inability to bathe or dress self.
    • Rationale:

      This answer is not correct because a client with Graves’ disease does not have a self-care deficit related to the inability to bathe or dress self. On the other hand, exophthalmos is a cardinal sign of Graves’ disease. This bulging of the eye anteriorly from the orbit makes it where the eye lid does not shut completely over the eye. This can cause extreme dryness which can lead to corneal abrasions.

  4. Impaired tissue integrity: Corneal related to dryness secondary to exophthalmos.
    • Rationale:

      This answer is correct because exophthalmos is a cardinal sign of Graves’ disease. This bulging of the eye anteriorly from the orbit makes it where the eye lid does not shut completely over the eye. This can cause extreme dryness which can lead to corneal abrasions. Dryness must be treated with lubricating eye drops to decrease corneal abrasions and increase comfort. The drops will supplement lubrication and decrease factors that may lead to lid retraction.

Overview

Exophthalmos is one of the cardinal signs of Graves’ disease. Since the eye bulges anteriorly from the orbit of the eye, the client is at risk for dryness and corneal abrasions.

Explanation

Learning Outcomes

Exophthalmos is a condition where the eye bulges anteriorly from the orbit of the eye. This condition is seen in Graves’ disease and orbital tumors. One of the cardinal signs of Graves’ disease is exophthalmos which causes eye dryness. Dryness must be treated with lubricating eye drops to decrease corneal abrasions and increase comfort. The drops will supplement lubrication and decrease factors that may lead to lid retraction.

Test Taking Tip

Using the knowledge of word parts can help the student understand what exophthalmos is: “exo-” means outside or external and “ophthal-” means related to the eyes.

Video Rationale