# Situation: A 68-year-old woman with newly diagnosed primary hypothyroidism and stable angina is started on levothyroxine 25 mcg daily. She also takes calcium carbonate and ferrous sulfate, each once daily. She wakes at 05:30 and eats breakfast at 06:30, lunch at 12:00, and dinner at 18:00. Before treatment, her angina came only when she climbed two flights of stairs and eased within minutes of rest. Some weeks after her dose is increased to 50 mcg daily, she calls the clinic. Which statement from her should the nurse report to the provider at once?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630405  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 68-year-old woman with newly diagnosed primary hypothyroidism and stable angina is started on levothyroxine 25 mcg daily. She also takes calcium carbonate and ferrous sulfate, each once daily. She wakes at 05:30 and eats breakfast at 06:30, lunch at 12:00, and dinner at 18:00.

Before treatment, her angina came only when she climbed two flights of stairs and eased within minutes of rest. Some weeks after her dose is increased to 50 mcg daily, she calls the clinic. Which statement from her should the nurse report to the provider at once?

## 보기

1. "My pulse is 88 now; it was 58 before the tablets."
2. "Now my chest gets tight when I walk to the bathroom." **✔ 정답**
3. "I still feel cold even on warm afternoons."
4. "I get chest tightness on two flights of stairs, as before."

**정답: 2**

## 해설

Thyroid hormone raises heart rate and myocardial oxygen demand, so in an older adult with coronary disease a dose increase can make angina worse. Angina that now comes with much less exertion is a changed, unstable pattern and is reported at once, whereas her usual stable pattern is unchanged baseline. A pulse rising from bradycardia into the normal range is an expected treatment effect.

## 심화 해설

The statement to report at once
She has stable angina and has recently had her levothyroxine dose increased to 50 mcg daily. Thyroid hormone raises heart rate and myocardial oxygen demand, so in an older adult with coronary disease a dose increase can make angina worse. Before treatment her angina came only after two flights of stairs. Chest tightness that now comes on walking to the bathroom is a changed, unstable pattern and is reported to the provider at once.

Why thyroid replacement can worsen angina
In hypothyroidism, metabolism and heart rate are slow, so the heart needs relatively little oxygen. Restoring thyroid hormone increases metabolic rate, heart rate, and contractility. In a client with narrowed coronary arteries, supply may not keep up with this higher demand, and angina appears with less exertion. That is why older adults and clients with coronary disease start levothyroxine at a low dose and increase it slowly. Angina occurring with minimal activity may signal an acute coronary syndrome and needs urgent assessment, possibly including a dose reduction.

| Statement | Interpretation | Action |
| --- | --- | --- |
| Pulse 88, was 58 | Correction of hypothyroid bradycardia | Expected |
| Chest tight walking to bathroom | Angina with minimal exertion: worsening | Report at once |
| Still feels cold | Hypothyroid symptom; improves gradually | Reassure; continue |
| Tightness on two flights, as before | Her known stable pattern | Baseline |

Why the other statements are not urgent
A resting pulse of 88/min is within the normal range; the rise from 58 reflects correction of hypothyroid bradycardia and is an expected treatment effect. Ongoing cold intolerance is a hypothyroid symptom that improves gradually over weeks as hormone levels normalize. Chest tightness on two flights of stairs is the same threshold as before treatment, so it is her known stable pattern rather than a change.

Nursing application
The nurse instructs her to stop activity and rest, follows the clinic protocol for chest pain, and notifies the provider immediately. Teaching for clients with heart disease starting thyroid replacement includes reporting new or worsening chest pain, palpitations, or shortness of breath.

Exam takeaway
Watch out The key is change from baseline. Angina at the usual exertion level is stable; angina at much lower exertion after a dose increase is unstable and urgent.

## 임상 시나리오

Levothyroxine and Worsening AnginaRecognizing a changed pattern
Thyroid hormone increases heart rate and myocardial oxygen demand. In an older adult with coronary disease, a dose increase can provoke angina at lower exertion.

Chest tightness on walking to the bathroom, when it previously needed two flights of stairs, is an unstable pattern and is reported at once. A pulse rising from 58 to 88 is an expected correction.

CautionStart levothyroxine low and increase slowly in older adults with heart disease. New or worsening chest pain needs urgent assessment.

## 핵심 개념

- **Stable angina** — Chest pain that occurs predictably with a given level of exertion and eases with rest.
- **Unstable angina** — Angina that is new, worsening, or occurring with minimal exertion or at rest; a medical emergency.
- **Myocardial oxygen demand** — The amount of oxygen the heart muscle needs, which rises with heart rate and contractility.
- **Hypothyroid bradycardia** — A slow heart rate caused by low thyroid hormone, which improves with replacement.

## 같은 주제 문제

- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630291)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630292)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630293)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630294)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630295)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630296)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630297)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630298)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._