The nurse assesses a client and notes tachypnea. Which respiratory rate reflects the nurse's assessment?

A. A bruit over the thyroid may indicate increased blood flow, which can occur in conditions such as Graves’ disease or hyperthyroidism. Auscultation is an important part of the assessment for clients with an enlarged thyroid to identify potential vascular abnormalities.

B. The thyroid is usually assessed with the client sitting upright with the neck slightly extended, as this position allows better visualization and palpation of the gland. Lying flat can make palpation more difficult and less accurate.

C. During thyroid palpation, the nurse typically asks the client to swallow, as swallowing elevates the thyroid and makes it easier to assess for size, nodules, or tenderness. Holding the breath is not part of standard thyroid assessment.

D. Percussion is not a standard method for assessing the thyroid. Palpation and auscultation are the primary assessment techniques. Percussion does not provide useful information about thyroid size, consistency, or vascularity.

A. Weigh the client is important for long-term monitoring of fluid balance and thyroid therapy, but in an acute myxedema coma, weight measurement is not a priority because the client’s immediate life-threatening risks are related to respiratory and cardiovascular compromise, not gradual weight changes.

B. Assessing the skin for bruising or discoloration is not a primary concern in myxedema coma. While hypothyroidism can cause dry, pale, or yellowish skin, bruising is not a hallmark of acute myxedema. This is secondary and not urgent.

C. Measuring the client’s respiratory rate and depth is a priority assessment because myxedema coma can cause hypoventilation, respiratory depression, and CO₂ retention. Early identification of respiratory compromise is critical for preventing hypoxia and respiratory failure.

D. Auscultating the client’s apical pulse is essential because myxedema coma can result in bradycardia, hypotension, and decreased cardiac output. Cardiovascular assessment is critical to detect life-threatening cardiac complications.

E. Assessing skin turgor on the forearm is generally used to assess dehydration, but in myxedema coma, the skin is often edematous (non-pitting myxedema), making turgor assessment less reliable and not a priority.