The nurse cares for a client with history of thyroid issues who presents with symptoms of suspected myxedema coma. What nursing assessments should the nurse prioritize? Select all that apply
Weigh the client
Assess the client's skin for bruising or discoloration
Measure the client's respiratory rate and depth
Auscultate the client's apical pulse
Assess the client's skin turgor on the forearm
Correct Answer : C,D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blue-tinged nail beds indicate cyanosis, which occurs when there is reduced oxygenation of hemoglobin in the blood. Cyanosis is often most visible in the lips, nail beds, and mucous membranes. While this is a critical finding, it does not represent pallor, which is a decrease in skin color due to reduced hemoglobin or blood flow, so this option is incorrect.
B. Yellow-range tinge color indicates jaundice, caused by elevated bilirubin and often associated with liver disease, hemolysis, or bile duct obstruction. Jaundice affects the skin and sclera, giving a yellowish appearance, but it is distinct from pallor, so this is also incorrect.
C. Ash-gray skin color is the most accurate description of pallor in clients with darker skin tones. In lighter skin, pallor may appear as pale or whitish, but in darker skin, the reduced hemoglobin content is less obvious, and the skin may appear ashen, gray, or dull. To assess pallor effectively in darker-skinned clients, the nurse should check areas with less pigmentation, such as the conjunctiva, lips, buccal mucosa, nail beds, and palmar creases. Using a descriptive term like “ash-gray” communicates the finding clearly to other healthcare providers and ensures proper follow-up for underlying causes, such as anemia, hypovolemia, or shock.
D. Patchy milk-white areas describe vitiligo, which is a chronic depigmentation disorder caused by loss of melanocytes. Vitiligo presents as well-demarcated, depigmented patches and is not related to acute changes in blood flow or oxygenation, so this option is incorrect.
Correct Answer is ["B","C","D"]
Explanation
A. An SpO₂ of 90% is below normal and indicates hypoxemia, not an expected age-related change. Normal oxygen saturation for older adults is generally 95–100% on room air. A reading of 90% requires assessment and possible intervention.
B. Older adults are more likely to develop age-related changes in cardiac conduction, including atrial fibrillation, premature beats, or other arrhythmias. These changes are often due to fibrosis of the conduction system, loss of pacemaker cells, and decreased myocardial elasticity, and may be anticipated as part of normal aging, though they may also require monitoring.
C. Older adults often have a lower baseline body temperature compared with younger adults due to reduced metabolic rate and decreased thermoregulatory responses. A temperature around 97°F is an expected age-related change and may mask fever in older adults.
D. Age-related changes in the respiratory system include decreased lung elasticity, weakened respiratory muscles, and reduced alveolar surface area, which may result in shallow breathing and slightly increased respiratory rates at rest. These are considered typical physiological changes with aging.
E. With aging, systolic blood pressure tends to increase, not decrease, due to stiffening of the arteries and decreased vascular compliance. Isolated systolic hypertension is common in older adults, whereas a decreased systolic BP is not expected as an age-related change.
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