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A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this client's plan of care?
- A. Monitor the electrolyte measurement once every shift
- B. Administer acetaminophen (Tylenol) for fever
- C. Ensure that working suction equipment is in the room
- D. Provide supplemental oxygen as needed
Correct Answer: C
Rationale: Clients with hypothyroidism and concurrent illness like pneumonia are at risk for myxedema coma, where maintaining an airway is critical. Ensuring working suction equipment is available is a priority to manage potential airway obstruction.
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A nurse assesses a client who is prescribed thyroid hormone replacement. Which finding indicates a therapeutic response to the medication?
- A. Thirst is recognized and fluid intake is appropriate
- B. Weight has been the same for 3 weeks
- C. Total white blood cell count is 6000 cells/mm³
- D. Heart rate is 70 beats/min and regular
Correct Answer: D
Rationale: Hypothyroidism decreases body functioning, leading to effects like bradycardia. A heart rate of 70 beats/min and regular while on thyroid hormone replacement indicates adequate dosing. Thirst, fluid intake, weight stability, and white blood cell count are not direct indicators of therapeutic response.
A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client's blood pressure, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?
- A. Serum potassium: 5.2 mEq/L
- B. Serum magnesium: 1.7 mEq/L
- C. Serum sodium: 144 mEq/L
- D. Serum calcium: 6 mg/dL
Correct Answer: D
Rationale: Hypocalcemia, indicated by a serum calcium level of 6 mg/dL, destabilizes excitable membranes, leading to muscle spasms and tetany, such as Trousseau's sign (flexion contractions). Potassium, magnesium, and sodium levels listed are not directly related to this condition.
A nurse cares for a client who has hypothyroidism as a result of Hashimoto's thyroiditis. The client asks, 'How long will I need to take this thyroid medication?' How should the nurse respond?
- A. You will need to take this thyroid medication until the goiter is completely gone
- B. Thyroiditis is cured with antibodies. Then you won't need thyroid medication
- C. You'll need thyroid pills for life because your thyroid won't start working again
- D. When blood cell count is 6000 cells/mm³, you can stop the medication
Correct Answer: C
Rationale: Hashimoto's thyroiditis causes permanent thyroid damage, requiring lifelong thyroid hormone replacement. The goiter may not resolve completely, antibodies do not cure thyroiditis, and blood cell count is unrelated to thyroid medication needs.
A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium 7.2 mg/dL, Sodium 144 mEq/L, Magnesium 1.2 mEq/L, Potassium 5.7 mEq/L. Based on these results, which medications should the nurse anticipate administering?
- A. Oral potassium chloride
- B. Intravenous calcium chloride
- C. 50% normal saline IV solution
- D. 50% magnesium sulfate
- E. Oral calcitriol (Rocaltrol)
Correct Answer: B,D
Rationale: The client has hypocalcemia (calcium 7.2 mg/dL) and hypomagnesemia (magnesium 1.2 mEq/L), requiring intravenous calcium chloride and magnesium sulfate. Potassium is elevated, so potassium chloride is not needed. Sodium is normal, so saline is unnecessary, and no vitamin D deficiency is indicated.
A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism?
- A. My sister has thyroid problems
- B. I seem to feel the heat more than other people
- C. Food just doesn't taste good without a lot of salt
- D. I am always tired, even with 12 hours of sleep
Correct Answer: D
Rationale: Clients with hypothyroidism often feel tired or weak despite adequate sleep. Thyroid problems are not necessarily inherited, heat intolerance suggests hyperthyroidism, and loss of taste is not a typical manifestation of hypothyroidism.