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A nurse is receiving a patient from the emergency room (ER) with an admitting diagnosis of hypothyroid disorder. 

Admitting diagnosis

acute hypothyroid disorder

Physician order

Synthroid 0.1 mg po daily

The receiving medical- surgical nurse would expect the patient to exhibit which signs and symptoms? Select all that apply

A.

cold intolerance

B.

depression dry skin

C.

weakness and fatigue

D.

constipation

E.

mental alertness

Question Solution

Correct Answer : A,B,C,D

A. Cold intolerance: Patients with hypothyroidism often have difficulty regulating body temperature, leading to a heightened sensitivity to cold.

 

B. Depression: Hypothyroidism can affect mood and cognitive function, often leading to symptoms of depression.

 

C. Weakness and fatigue: Low thyroid hormone levels can cause significant fatigue and muscle weakness due to a slower metabolism.

 

D. Constipation: A slowed metabolism can also affect gastrointestinal motility, resulting in constipation.

 

E. Mental alertness: This is typically not expected in hypothyroid patients. In fact, they may experience cognitive impairments, memory issues, or slowed thinking rather than mental alertness.


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Correct Answer is C

Explanation

A. A BMI of 26 is not classified as obese; obesity typically starts at a BMI of 30.

B. Underweight is defined as a BMI less than 18.5, which does not apply to this client.

C. A BMI of 26 falls within the overweight category, which is defined as a BMI between 25 and 29.9.

D. A healthy weight is classified as a BMI between 18.5 and 24.9, which does not include a BMI of 26.

Correct Answer is C

Explanation

A. The patient's chart may provide historical information but does not reflect the current pain intensity the client is experiencing.

B. Visual observation for nonverbal signs of pain can be useful, especially for nonverbal patients, but self-reporting is the most accurate measure of pain intensity.

C. The client's self-report of pain severity is the gold standard for assessing pain intensity, as it reflects the individual’s personal experience of pain.

D. While the nature and invasiveness of the surgical procedure can provide context for expected pain levels, they do not replace the importance of the client's self-report in managing pain effectively.

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