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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 B

Explanation

A. Obesity is a modifiable risk factor, as it can be addressed through lifestyle changes such as diet and exercise.

B. Race is a nonmodifiable risk factor; certain races may have a higher risk of stroke due to genetic and environmental factors.

C. History of smoking is a modifiable risk factor because individuals can choose to quit smoking to reduce their risk of stroke.

D. History of hypertension is also a modifiable risk factor; while having high blood pressure increases the risk of stroke, it can be managed with lifestyle changes and medications.

Correct Answer is A

Explanation

A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.

B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.

C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.

D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.

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