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
cold intolerance
depression dry skin
weakness and fatigue
constipation
mental alertness
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. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.
B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.
C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.
D. Grimacing is an objective observation by the nurse, not a subjective report from the client.
Correct Answer is C
Explanation
A. This would show a regular rhythm with a consistent rate (60-100 bpm) and clear P waves before each QRS complex, which is not present in asystole.
B. This indicates a slow heart rate (below 60 bpm) but would still display P waves and QRS complexes; asystole shows no electrical activity.
C. This is the correct interpretation as it represents a flatline on the ECG, indicating no electrical activity in the heart.
D. This would show a rapid heart rate (above 100 bpm) with present P waves, which is not the case in asystole.