A client who is admitted for primary hypothyroidism has early signs of myxedema coma.
In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.).

Palpate for pedal edema.

Assess blood pressure.

Measure body temperature.

Observe breathing patterns.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Altered consciousness within the first 24 hours after injury is not indicative of a developing epidural hematoma. An epidural hematoma typically manifests as a lucid interval followed by a rapid deterioration in consciousness hours after the injury.

Choice B rationale:

Cushing reflex (increased blood pressure, bradycardia, and irregular respirations) and cerebral edema after 24 hours are characteristic signs of a developing epidural hematoma. This occurs due to the accumulation of blood between the dura mater and the skull, leading to increased intracranial pressure.

Choice C rationale:

Headache and pupillary changes 48 hours after head injury are not specific signs of an epidural hematoma. These symptoms may indicate various other neurological conditions or complications.

Choice D rationale:

Fever, nuchal rigidity, and opisthotonos within hours are suggestive of meningitis rather than an epidural hematoma. These symptoms are not typical of epidural hematomas, which primarily involve alterations in consciousness and increased intracranial pressure.

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Correct Answer is D

Explanation

Choice A rationale:

Checking the client's temperature is important for assessing the client's condition, but it is not a priority before administering penicillin G IV for meningitis.

Choice B rationale:

Assessing the client's level of consciousness is essential for monitoring neurological status, but it is not the highest priority action before administering penicillin G IV for meningitis.

Choice C rationale:

Asking the client about any history of allergies is important for assessing potential allergic reactions to medications. However, the most critical action before administering penicillin G IV for meningitis is to obtain a blood sample for culture and sensitivity. This action helps identify the causative organism and guides appropriate antibiotic therapy, as meningitis can be life-threatening and requires prompt treatment.

Choice D rationale:

Obtaining a blood sample for culture and sensitivity is the highest priority action before administering penicillin G IV for meningitis. Identifying the specific pathogen responsible for the infection is crucial for selecting the most effective antibiotic therapy and preventing complications.

A. Decreasing gastrointestinal (GI) cramping and nausea. B. Chest pain and dysrhythmia. C. Vasodilation of the extremities. D. Hypotension and tachycardia.

Correct Answer is B

Explanation

The correct answer is B

Choice A reason: Vasopressin is not typically associated with decreasing GI cramping and nausea. It is used to treat diabetes insipidus and to reduce stomach bloat for some procedures and after some surgeries.

Choice B reason: Vasopressin can cause chest pain or pressure, and fast, slow, or abnormal heartbeat, which are indicative of dysrhythmia. These are known side effects of vasopressin and should be monitored during IV infusion.

Choice C reason: Vasopressin causes vasoconstriction, not vasodilation. It tightens small blood vessels, which is the opposite of vasodilation.

Choice D reason: While vasopressin can cause bradycardia (slow heart rate), hypotension is not a common effect as it is used to treat low blood pressure. Tachycardia (fast heart rate) is not a typical side effect of vasopressin.

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A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has meningitis caused by Streptococcus pneumoniae. The provider orders penicillin G IV for this client. Before administering the medication, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication?

Correct Answer is B

Explanation

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A client who is admitted for primary hypothyroidism has early signs of myxedema coma.
In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.).