A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?

Initiate measures to cool the client

Turn the client every 4 hr

Place the client on aspiration precautions

Check the client’s blood pressure every 2 hr

Answer and Explanation

The Correct Answer is C

Choice A reason: Initiating cooling measures is inappropriate for myxedema coma, a hypothyroid crisis causing hypothermia due to low metabolic rate. Warming measures are needed to correct hypothermia, as cooling exacerbates the condition, making this an incorrect and potentially harmful intervention.

Choice B reason: Turning the client every 4 hours prevents pressure ulcers but is not the priority in myxedema coma. Aspiration risk from depressed consciousness and respiratory drive is more immediate, requiring precautions to protect the airway, making this a secondary intervention.

Choice C reason: Placing the client on aspiration precautions is critical in myxedema coma, as severe hypothyroidism causes depressed consciousness and respiratory drive, increasing aspiration risk. Precautions like elevating the head of the bed protect the airway, addressing the immediate life-threatening risk in this condition.

Choice D reason: Checking blood pressure every 2 hours is important but not the priority in myxedema coma. Hypotension occurs, but aspiration risk from altered mental status and respiratory depression poses a greater immediate threat, making aspiration precautions the primary intervention.

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Correct Answer is B

Explanation

Choice A reason: Administering a diuretic is contraindicated in diabetes insipidus, as it exacerbates water loss, worsening dehydration. DI requires interventions like vasopressin or fluid replacement to correct dilute urine output, making diuretics harmful and inappropriate for managing this condition’s pathophysiology.

Choice B reason: Checking urine specific gravity is essential in DI, as low values (e.g., 1.000-1.005) indicate dilute urine from deficient antidiuretic hormone, confirming diagnosis and guiding treatment. Monitoring helps assess vasopressin effectiveness and fluid status, making it a critical intervention in DI care.

Choice C reason: Measuring blood glucose every 4 hours is irrelevant to DI, which involves water balance, not glucose metabolism. Glucose monitoring is key in diabetes mellitus, not DI, where polyuria results from ADH deficiency, making this intervention unrelated to the condition’s management.

Choice D reason: Initiating fluid restrictions is inappropriate for DI, as it worsens dehydration caused by excessive water loss from low ADH. Fluid replacement or vasopressin is needed to restore water balance, making fluid restriction a harmful intervention that exacerbates DI’s hypovolemic state.

A. Diarrhea B. Facial edema C. Bradycardia D. Weight gain

Correct Answer is A

Explanation

Choice A reason: Diarrhea is a hallmark of hyperthyroidism, as excess thyroid hormone accelerates gastrointestinal motility via increased sympathetic activity and metabolic rate. This leads to frequent, loose stools, reflecting the hypermetabolic state’s impact on intestinal transit, making it a primary expected finding.

Choice B reason: Facial edema is not typical in hyperthyroidism, which causes warm, moist skin or exophthalmos. Edema is associated with hypothyroidism due to fluid retention from low metabolism, making this an incorrect finding for hyperthyroidism’s clinical presentation.

Choice C reason: Bradycardia is not expected in hyperthyroidism, which causes tachycardia due to thyroid hormone’s stimulation of beta-adrenergic receptors, increasing heart rate. Bradycardia occurs in hypothyroidism, making this an incorrect manifestation for hyperthyroidism’s cardiovascular effects.

Choice D reason: Weight gain is not associated with hyperthyroidism, which causes weight loss due to increased metabolic rate burning calories. Weight gain is typical of hypothyroidism, where metabolism slows, making this an incorrect finding for hyperthyroidism’s metabolic profile.

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A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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