An overweight African-American female client with a diagnosis of hypothyroidism asks the nurse why she has begun to gain body weight. Which is the best explanation the Medical Surgical nurse can provide?

"Your metabolism is slowing down."

"You should be exercising for longer periods of time."

"You could be making healthier food choices."

"You are retaining fluid."

Answer and Explanation

The Correct Answer is A

(a) "Your metabolism is slowing down.":

Hypothyroidism leads to a decrease in the production of thyroid hormones, which are critical in regulating metabolism. With lower levels of these hormones, the body's metabolic rate decreases, resulting in reduced calorie burning and subsequent weight gain. This explanation directly addresses the underlying cause of weight gain in hypothyroidism.

(b) "You should be exercising for longer periods of time.":

While exercise is beneficial for overall health and can help manage weight, it does not directly address the reason for weight gain in hypothyroidism. The primary issue is the slowed metabolism due to thyroid hormone deficiency, not a lack of exercise.

Although diet plays a role in weight management, this response does not explain the root cause of weight gain in hypothyroidism. The condition itself slows metabolism, leading to weight gain even if dietary habits remain unchanged.

(d) "You are retaining fluid.":

Fluid retention can occur in hypothyroidism but is not the primary reason for weight gain in this condition. The main cause is a decreased metabolic rate, which leads to the accumulation of body fat. Fluid retention might contribute to some weight gain, but it is not the best explanation in this context.

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Correct Answer is C

Explanation

The Body Mass Index (BMI) is calculated using the formula:

BMI = weight(kg) / height(m)2

First, we need to convert the height from feet and inches to meters.

There are approximately 0.3048 meters in a foot and 0.0254 meters in an inch.

So, 5 feet 5 inches is approximately 1.65 meters.

Substituting the given values into the formula:

BMI = 60 / (1.65)2

This gives us a BMI of approximately 22 when rounded to the nearest whole number.

Therefore, the correct answer is 22 BMI.

A. Stage I B. Stage III C. Stage IV D. Stage II

Correct Answer is D

Explanation

Stage I: Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin. There is no break in the skin, but it may appear red and warm to the touch. It is considered the mildest form of pressure injury, signaling the beginning of potential skin damage.

B) Stage III: Stage III pressure ulcers involve full-thickness skin loss. This means that the damage extends through the dermis into the subcutaneous tissue. There may be visible fat, but bone, tendon, and muscle are not exposed. These ulcers are deeper and more serious than the scenario described.

C) Stage IV: Stage IV pressure ulcers are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. The presence of slough or eschar may be present on some parts of the wound bed, and these ulcers are deep, often with extensive damage and infection.

D) Stage II: Stage II pressure ulcers are characterized by partial-thickness skin loss involving the epidermis and/or dermis. They present as shallow, open ulcers with a red-pink wound bed, without slough. They may also appear as intact or open/ruptured serum-filled blisters, which matches the description given in the scenario. This stage represents a more significant injury than Stage I but does not extend into the deeper layers of skin and tissue as in Stage III and IV.

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An overweight African-American female client with a diagnosis of hypothyroidism asks the nurse why she has begun to gain body weight. Which is the best explanation the Medical Surgical nurse can provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a 60kg adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client? Round to the whole number.

Correct Answer is C

Explanation

The nurse notes a break in the skin, which appears blister-like, it looks superficial with loss up to the dermis layer. The nurse would interpret this finding as indicating which stage of pressure ulcer.

Correct Answer is D

Explanation

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