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

Check the patient’s blood pressure every two hours

Place the patient on aspiration precautions

Initiate measures to cool the patient

Turn the patient every four hours

Answer and Explanation

The Correct Answer is B

Choice A reason: Checking blood pressure every two hours is insufficient in myxedema coma, a critical condition requiring frequent monitoring (e.g., every 15–30 minutes) due to hypotension and shock risk. Hypothyroidism slows metabolism, causing cardiovascular instability, necessitating closer observation to detect deterioration and guide fluid or vasopressor therapy.

Choice B reason: Aspiration precautions are critical in myxedema coma, as altered consciousness and hypoventilation increase aspiration risk. Severe hypothyroidism depresses respiratory drive and gag reflex, raising the chance of inhaling oral secretions or vomit. Elevating the head and monitoring swallowing protect the airway, making this a priority intervention.

Choice C reason: Cooling measures are inappropriate, as myxedema coma causes hypothermia due to reduced metabolism. Patients need passive warming to correct low body temperature, as hypothermia exacerbates cardiovascular and neurological dysfunction. Cooling would worsen the patient’s condition, making this an incorrect and harmful intervention.

Choice D reason: Turning the patient every four hours prevents pressure ulcers but is not the priority in myxedema coma. Acute management focuses on airway protection, thyroid hormone replacement, and hemodynamic stabilization. While mobility is important long-term, aspiration risk from altered consciousness takes precedence in this life-threatening hypothyroid crisis.

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Correct Answer is B

Explanation

Choice A reason: NSTEMI (non-ST-elevation myocardial infarction) is a heart attack caused by coronary artery occlusion, leading to myocardial ischemia. Symptoms include chest pain and elevated cardiac enzymes, not bradycardia, hyponatremia, or altered consciousness. Hypothyroidism does not directly cause NSTEMI, and these symptoms align with metabolic, not cardiac, pathology.

Choice B reason: Myxedema coma is a life-threatening complication of severe hypothyroidism, characterized by bradycardia, hyponatremia, hypotension, altered consciousness, and respiratory depression. Hypothyroidism slows metabolism, leading to fluid retention, low sodium, and reduced cardiac output. These symptoms match the patient’s presentation, making myxedema coma the most likely diagnosis in this scenario.

Choice C reason: SIADH causes hyponatremia due to excessive antidiuretic hormone, leading to water retention. However, it does not typically cause bradycardia, hypotension, or respiratory difficulty. SIADH is not a complication of hypothyroidism, and the patient’s symptoms, including altered consciousness, align more closely with myxedema coma than SIADH’s water imbalance.

Choice D reason: Thyroid storm is a life-threatening hyperthyroidism complication, presenting with tachycardia, hyperthermia, and agitation. The patient’s bradycardia, hypotension, and hyponatremia are opposite to thyroid storm’s hypermetabolic state. Hypothyroidism leads to myxedema coma, not thyroid storm, making this choice inconsistent with the patient’s clinical presentation and lab findings.

A. Redness of the anus B. Stomatitis C. Intestinal inflammation D. Increased body temperature

Correct Answer is D

Explanation

Choice A reason: Redness of the anus is a local response to irritation from frequent diarrhea in gastroenteritis, not a systemic response. Systemic responses involve the whole body, like fever, driven by cytokine release. Anal redness is a localized tissue reaction, not reflective of the broader inflammatory process in this infection.

Choice B reason: Stomatitis, or mouth inflammation, is not a systemic response to gastroenteritis. It may occur in specific infections (e.g., herpes) but is not typical in gastroenteritis, which primarily affects the intestines, causing diarrhea and dehydration. Systemic responses involve fever or leukocytosis, not localized oral inflammation, making this choice incorrect.

Choice C reason: Intestinal inflammation is a local response in gastroenteritis, causing diarrhea and abdominal pain. Systemic responses, like fever, result from cytokines (e.g., IL-1, IL-6) released during infection, affecting the entire body. Intestinal inflammation is the primary pathology, not a systemic effect, so this does not fit the question’s focus.

Choice D reason: Increased body temperature (fever) is a systemic response to gastroenteritis, triggered by cytokines (e.g., IL-1, TNF) released during infection. These signal the hypothalamus to raise body temperature, enhancing immune response. The patient’s feeling of warmth aligns with fever, a common systemic manifestation of inflammatory infections like gastroenteritis.

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A nurse is caring for a patient 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 B

Explanation

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Correct Answer is D

Explanation

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