While performing an assessment of the integument system, the nurse not

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 should the nurse use to document this finding?

1. Erythema
2. Cyanosis
3. Exophthalmos
4. Normocephalic

ANSWER

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.