Which assessment finding(s) for a client with hypothyroidism should the nurse document as abnormal? Select all that apply.

Poor dentition

Skin is pink, dry and warm

Client states, "I can't seem to get warm lately"

Weight gain of five pounds in two months

Periorbital non-pitting edema

Answer and Explanation

Correct Answer : A,C,E

A.   Poor dental health can be linked to hypothyroidism, as it may cause a decrease in oral health.
B.   Skin should be dry and cool in hypothyroidism, making this finding abnormal.
C.   Client states, "I can't seem to get warm lately." Cold intolerance is a hallmark symptom of hypothyroidism due to slowed metabolism.
D.   Weight gain of five pounds in two months. Mild weight gain can occur in hypothyroidism but may not be significant enough to consider abnormal without other symptoms.
E.   Periorbital non-pitting edema. This finding is common in hypothyroidism and indicates water retention around the eyes.

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Correct Answer is A

Explanation

A. The whispered voice test is used to assess the function of Cranial Nerve VIII, which is responsible for hearing and balance. The nurse's whisper tests the auditory function of this nerve.
B. The vagus nerve is involved in swallowing, voice production, and parasympathetic functions but is not assessed by whispering.
C. This nerve controls lateral eye movement, and a whispered voice test does not assess eye movement.
D. This nerve also controls eye movement, specifically the superior oblique muscle, and is not evaluated by the whispered voice test.

A. May indicate disease of the cerebellum or brainstem. B. is a sign that the patient is nervous about the examination C. Indicates a visual problem, and a referral to an ophthalmologist is indicated. D. is a normal occurrence

Correct Answer is A

Explanation

A. Severe nystagmus is often associated with neurological disorders, particularly those affecting the cerebellum or brainstem.
B. is a sign that the patient is nervous about the examination. Nervousness typically doesn’t cause severe, persistent nystagmus.
C. Indicates a visual problem, and a referral to an ophthalmologist is indicated. While nystagmus affects vision, it is usually neurologically based, requiring a neurological assessment rather than a referral to an ophthalmologist.
D. Nystagmus is not typically normal, especially when it is severe and persistent. It warrants further investigation.

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Which assessment finding(s) for a client with hypothyroidism should the nurse document as abnormal? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse stands behind the client and whispers "5-B-6." This technique is used to assess which of the following Cranial Nerves?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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