Author Question: The nurse is planning care for a client with hypothyroidism. Which is the priority nursing diagnosis ... (Read 131 times)

bobthebuilder · **on:** Jun 25, 2018

The nurse is planning care for a client with hypothyroidism. Which is the priority nursing diagnosis for this client?

1. Risk for constipation related to metabolic imbalance.
2. Activity intolerance related to fatigue.
3. Risk for injury related to confusion and lethargy.
4. Altered nutrition, less than body requirements.

Question 2

The nurse is examining a client's neck. Which techniques are appropriate when palpating the trachea?

Select all that apply.
1. Palpate while the client is swallowing.
2. Slide the thumb and index finger upward on each side of the trachea.
3. Palpate the midline of the neck to feel the cricoid cartilage.
4. Ask the client to open and close her mouth.
5. Stand behind the client and ask her to turn her head slightly to the right.

bulacsom · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer:2
Feeling tired, exhausted, and not having enough energy to perform even small tasks is a typical complaint from clients suffering from hypothyroidism. While confusion, lethargy, and constipation are commonly associated with hypothyroidism, these are conditions that are a risk and not present according to the nursing diagnosis statement, and therefore do not carry the same priority as those that are actually present. Typically, the client with hypothyroidism, though he may not have an appetite, may be gaining weight.

Answer to Question 2

Correct Answer: 1, 2, 3
The nurse should use his thumb and index finger to identify the thyroid cartilage as he slides these fingers up the client's neck. The nurse should confirm that the hyoid bone and tracheal cartilages move up when the client swallows. The trachea should be midline. The C rings are also called cricoid cartilage. The client should be asked to open and close her mouth during inspected and palpation of the temporomandibular joint. Stand behind the client and asking the client to turn her head slightly to the right causes the neck muscles to relax and is done when palpating the thyroid not the trachea.