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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Correcting electrolytes that are out of normal range is a crucial goal of therapy for this client. In diabetic ketoacidosis (DKA), the body’s cells are unable to use glucose for energy due to a lack of insulin. This leads to the breakdown of fat for energy, producing ketones as a by-product. Ketones are acidic and can cause the blood’s pH to decrease, leading to metabolic acidosis. This process also leads to an increased production and excretion of electrolytes such as potassium and sodium. Therefore, correcting these electrolyte imbalances is a key goal of therapy.
Choice B rationale:
While promoting oxygenation to tissues is generally important in critical care, it is not a specific goal in the management of DKA. The primary issues in DKA are metabolic in nature, including hyperglycemia, ketosis, and acidosis.
Choice C rationale:
Preventing hyperventilation is not a specific goal in the management of DKA. Hyperventilation in DKA is a compensatory mechanism for metabolic acidosis (Kussmaul breathing). The body tries to expel more carbon dioxide to reduce the acidity of the blood.
Choice D rationale:
Reversing dehydration is another important goal of therapy for this client. In DKA, high blood glucose levels lead to osmotic diuresis, where water is drawn into the urine from the blood, leading to dehydration. This can cause hypotension and reduced tissue perfusion. Therefore, reversing dehydration through fluid replacement is a key part of treatment.
Choice E rationale:
Replacing insulin is a fundamental goal of therapy for this client. Insulin deficiency is the primary cause of DKA. Insulin allows glucose to enter cells where it can be used for energy, preventing the breakdown of fat for energy and the subsequent production of ketones.
Choice F rationale:
Providing respiratory support may be necessary in severe cases of DKA where the patient’s compensatory respiratory efforts are insufficient to maintain adequate gas exchange. However, it is not one of the primary goals of therapy in DKA management.
Correct Answer is B
Explanation
Choice A rationale:
The statement, "This medication will shorten the duration of my symptoms," is correct. Oseltamivir is an antiviral medication used to treat influenza, and it can reduce the duration of symptoms when taken early in the course of the illness.
Choice B rationale:
The statement, "This medication will prevent me from spreading the virus to others," is incorrect. While oseltamivir can help reduce the severity and duration of symptoms, it does not prevent the spread of the virus to others. Clients with influenza should still take precautions to avoid transmitting the virus to others.
Choice C rationale:
The statement, "This medication will work best if I start taking it within 48 hours of symptom onset," is correct. Oseltamivir is most effective when started within 48 hours of the onset of symptoms.
Choice D rationale:
The statement, "This medication may cause nausea and vomiting as side effects," is correct. Nausea and vomiting are potential side effects of oseltamivir, and clients should be informed about these possible adverse reactions.
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