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 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.
Correct Answer is A
Explanation
- A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suffering and improving the quality of life for the client and their family.
- An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admited to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care.
- A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation.
- Health care proxy documentation is an important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reflects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because the name of the funeral home to contact is not relevant or necessary for the admission assessment of a terminally ill client, as it does not affect their health status or care plan.
Option C is incorrect because the client's wishes regarding organ donation may be included in their health care proxy documentation, but they are not required or essential for the admission assessment of a terminally ill client.
Option D is incorrect because the contact information for the client's next of kin may be useful for communication and support purposes, but it is not as important as the health care proxy documentation for the admission assessment of a terminally ill client.
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