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 B

Explanation

Choice A rationale

A lung biopsy is an invasive procedure that is typically performed to diagnose conditions such as lung cancer or interstitial lung disease. It is not the first-line test for evaluating increased shortness of breath in a client with COPD56.

Choice B rationale

Spirometry is a common, non-invasive test used to assess lung function and is particularly useful in conditions like COPD. It measures the volume and speed of air a person can inhale and exhale, which can help in assessing the severity of COPD56.

Choice C rationale

Antibody testing is typically used to diagnose conditions related to the immune system, such as allergies or autoimmune diseases. It is not typically used to evaluate shortness of breath in a client with COPD56.

Choice D rationale

A sweat test is used to diagnose cystic fibrosis by measuring the amount of salt in a person’s sweat. It is not used to evaluate shortness of breath in a client with COPD56.

A. Observe for signs of depression. B. Apply sequential compression stockings. C. Monitor for urinary incontinence. D. Provide a wide variety of meal choices.

Correct Answer is A

Explanation

Choice A rationale

Observing for signs of depression is the most important intervention for the nurse to include in the client’s plan of care. This patient has a history of struggling with weight management, diabetes mellitus, and hypertension, and is now approved for gastroplasty. Weight management surgery can have significant psychological implications, and patients may experience depression or other emotional issues. Identifying signs of depression and providing appropriate support and resources is crucial for the client’s overall well-being and successful outcomes.

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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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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.)