A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

Measure body temperature.

Palpate for pedal edema.

Observe breathing patterns.

Assess blood pressure.

Answer and Explanation

The Correct Answer is C,A,D,B

Step 1: Observe breathing patterns. Respiratory depression is a critical symptom of myxedema coma that requires immediate attention.

Step 2: Measure body temperature. Hypothermia is a common symptom of myxedema coma and can provide important information about the severity of the patient’s condition.

Step 3: Assess blood pressure. Hypotension can occur in myxedema coma and can indicate the severity of the patient’s condition.

Step 4: Palpate for pedal edema. While this can be a symptom of hypothyroidism, it is not typically a primary concern in a patient showing signs of myxedema coma.

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Correct Answer is C

Explanation

Choice A rationale

Reducing the infant’s fruit intake for 24 hours is not the best approach in this situation. While certain fruits can cause diarrhea, the parent reports no signs of watery stools. Therefore, this intervention may not address the issue of the red and raw diaper area.

Choice B rationale

Cleaning with soap and water at each diaper change can actually worsen the condition. Soap can dry out the skin and disrupt the skin’s natural barrier, potentially leading to more irritation. It’s generally recommended to use water and a soft cloth, or a gentle non-soap cleanser, to clean the diaper area.

Choice C rationale

Changing the child’s diaper more frequently is the most appropriate intervention. A wet or dirty diaper can irritate the skin, leading to diaper rash. By changing the diaper more often, the skin is kept clean and dry, which can help the rash heal.

Choice D rationale

Applying lotion with each diaper change is not typically recommended for diaper rash. Some lotions can contain fragrances or other ingredients that can further irritate the rash. Instead, a barrier cream or ointment, such as one containing zinc oxide, is often recommended.

A. Yogurt or buttermilk. B. Green leafy vegetables. C. Avocados and cheese. D. Fresh fruits.

Correct Answer is A

Explanation

Choice A rationale

The antibiotic cefdinir is used to treat many different types of infections caused by bacteria. While a balanced diet is important for overall health, yogurt or buttermilk is a better choice due to their probiotic content, which may promote gut health and support the immune system.

Choice B rationale

Green leafy vegetables are rich in vitamins and minerals, but they are not a primary focus for a client with a postoperative wound infection. The emphasis should be on foods that support the immune system and overall recovery, such as yogurt or buttermilk.

Choice C rationale

Avocados and cheese are not specifically recommended for a client with a postoperative wound infection. While these foods are part of a balanced diet, they do not have specific benefits for a person taking cefdinir.

Choice D rationale

Fresh fruits are generally a healthy dietary choice, but they are not particularly relevant to the management of a postoperative wound infection. The emphasis for this client should be on foods that support wound healing and immune function, such as yogurt or buttermilk.

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A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

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The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

Correct Answer is C

Explanation

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection.What foods should the nurse encourage this client to eat?

Correct Answer is A

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A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)