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 D,B,C,A

Rationalizing the Priority
1. Airway/Breathing (D):
The "A" and "B" of the ABCs take precedence. In myxedema coma, hypoventilation is a primary concern. The client may experience respiratory muscle weakness or a decreased drive to breathe, leading to CO₂ retention and respiratory failure. Assessing the rate, depth, and effort of breathing is the absolute first step.

2. Circulation (B):
Once the airway is confirmed, you assess the "C" (Circulation). Myxedema coma causes severe bradycardia and decreased cardiac output, which leads to hypotension. Assessing blood pressure tells the nurse if the client is in cardiogenic shock.

3. Vital Signs/Metabolic State (C):
Hypothermia is a hallmark sign of myxedema coma (temperatures can often drop below 95°F or 35°C). While critical, it is addressed after ensuring the heart is pumping and the lungs are moving air. Monitoring temperature is vital because rapid rewarming can actually cause vasodilation and worsen shock.

4. Focused Physical Assessment (A):
Palpating for edema is an important part of a head-to-toe assessment for hypothyroidism (non-pitting mucinous edema is common), but it is not a life-saving intervention. It is a secondary assessment compared to the vital signs and respiratory status.

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Correct Answer is A

Explanation

Choice A rationale: The spasm described is Trousseau's sign, a classic indicator of hypocalcemia. Inflating a blood pressure cuff above systolic pressure causes carpal spasm due to increased neuromuscular irritability, requiring immediate assessment of serum calcium levels.

Choice B rationale: Carpal spasms during blood pressure measurement are a physiological manifestation of electrolyte imbalance, not psychological distress. Administering antianxiety medication would delay necessary treatment for a potentially life-threatening calcium deficiency.

Choice C rationale: Moving the cuff to the other arm would likely produce the same result because hypocalcemia is a systemic condition. This action ignores the underlying physiological cause and fails to address the client's safety.

Choice D rationale: The spasms are a physical reaction from the client, not a malfunction of the equipment. Replacing the sphygmomanometer would be an ineffective intervention that misses the clinical significance of the sign.

A. Report the finding to the healthcare provider. B. Document the purposeful response to pain. C. Initiate seizure precautions immediately. D. Administer a prescribed PRN analgesic.

Correct Answer is A

Explanation

Choice A rationale: The described posture is decorticate posturing, a sign of severe brain damage. This indicates a deteriorating neurological status and requires immediate reporting to the healthcare provider to prevent further injury.

Choice B rationale: The client's response is a non-purposeful, reflexive motor movement rather than a purposeful attempt to remove the painful stimulus. Documenting it as a purposeful response would be clinically inaccurate and misleading.

Choice C rationale: While neurological injury increases seizure risk, decorticate posturing is a direct sign of midbrain or cortical dysfunction. The immediate priority is addressing the underlying cause of the abnormal posturing and neurological decline.

Choice D rationale: Administering an analgesic could mask further neurological changes and depress the central nervous system. The priority is a full neurological assessment and notifying the physician of the client's severe motor response.

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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

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Correct Answer is A

Explanation

Correct Answer is A

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.).