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 D

Explanation

A. Although the medical record can provide background information, it does not give the real-time assessment of the patient's current functional abilities.
B. While this information can be valuable, observing the patient directly provides the most accurate assessment of his abilities.
C. The physician’s perspective is important but may not fully capture the patient's day-to-day functional capacity.
D. Direct observation allows the nurse to assess the patient’s current functional status and make necessary adjustments to the care plan.

A. Third level priority B. First level priority C. Routine D. Second level priority

Correct Answer is B

Explanation

A. This category refers to non-urgent problems, which does not apply here as the client is showing signs of severe distress and requires immediate attention.
B. Central cyanosis, a low heart rate (bradycardia), and low blood pressure are life-threatening signs that necessitate immediate intervention to stabilize the patient.
C. This is not a routine or minor situation. The client is in critical condition and requires urgent intervention.
D. While second-level priorities are important, this patient has life-threatening signs requiring first-level priority, immediate action, and stabilization.

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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

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