A 25 -year-old client with Grave's disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

Exophthalmos (bulging eyes) is a hallmark sign of Grave's disease, directly resulting from the autoimmune process.
It is caused by inflammation and the accumulation of fluid and fat in the tissues behind the eyes (retro-orbital space).
This sign is specific to Grave's disease and helps differentiate it from other causes of hyperthyroidism.

Option A: Bradycardia (slow heart rate) is incorrect. The hypermetabolic state in Grave's disease causes tachycardia (fast heart rate).
Option B: Decreased appetite is incorrect. The high metabolic rate in Grave's disease leads to an increased appetite (polyphagia).
Option D: Weight gain is incorrect. Despite an increased appetite, patients with Grave's disease typically experience weight loss due to the accelerated metabolism.

Clinical Relevance

Nursing practice connection: Use the key finding related to Clinical manifestations of Grave's disease to guide bedside assessment, documentation, and the next nursing action.
A primary nursing responsibility for patients with exophthalmos is protecting the cornea from injury due to incomplete eyelid closure. This includes administering artificial tears, teaching the patient to wear sunglasses, and elevating the head of the bed.
Nurses must monitor for signs of thyroid storm (thyrotoxic crisis), a life-threatening complication of Grave's disease characterized by high fever, extreme tachycardia, and altered mental status. It can be precipitated by stress, infection, or surgery.
What if? If the client presented with cold intolerance, fatigue, and weight gain, the nurse would suspect hypothyroidism, not Grave's disease. The assessment findings would be the opposite of those seen in hyperthyroidism.

How to Approach the Question

First, identify the core concept of the question, which is the clinical presentation of Grave's disease.
Recall that Grave's disease is the most common cause of hyperthyroidism, leading to a hypermetabolic state.
Systematically evaluate each option against the known pathophysiology of hyperthyroidism.
Eliminate options that are signs of hypothyroidism (bradycardia, decreased appetite, weight gain).
Identify exophthalmos as the unique, hallmark sign of Grave's disease, confirming it as the correct answer.

Concept Tested & Keywords

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 4 p. 20-22

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 1224-1226

Practise the full DHS Staff Nurse - 2018 (Shift-2nd)

Attempt every question from this paper in a timed mock, then review the full solution for each one.