Physiological Integrity Q 2

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A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

  

     A. Impaired physical mobility related to decreased endurance

     B. Hypothermia r/t decreased metabolic rate

     C. Disturbed thought processes r/t interstitial edema

     D. Decreased cardiac output r/t bradycardia

    

    

Correct Answer: D. Decreased cardiac output r/t bradycardia

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The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices. Protect against coldness. Provide extra layers of clothing or extra blankets. Discourage and avoid the use of external heat sources. Monitor patient’s body temperature.

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Option A: Impaired physical mobility is not applicable to a client with hypothyroidism. Promote rest. Space activities to promote rest and exercise as tolerated. Assess the client’s ability to perform activities of daily living (ADLs). The client may experience fatigue with minimal exertion due to a slow metabolic rate. This symptom hinder the client’s ability to perform daily activities (e.g., self-care, eating)

Option B: Hypothermia is correct but not a priority. Teach the expected benefits and possible side effects. The client should report symptoms such as chest pain/palpitations; these happen due to the increased metabolic and oxygen consumption.

Option C: Disturbed thought processes is not a related diagnosis. Assess the client’s appetite. Clients with hypothyroidism have decreased appetite. This opposite relationship between weight gain and decreased appetite is a manifestation found in hypothyroidism.

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