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 ["A","D"]

Explanation

Choice A rationale:

The educational materials should contain a list with definitions of unfamiliar terms because older clients may not be familiar with medical terminology. Providing definitions can enhance their understanding of the new antihypertensive medications and promote medication adherence.

Choice B rationale:

Writing materials at a twelfth-grade reading level may not be appropriate for older clients. Many older individuals may have lower literacy levels, and using complex language can lead to confusion and hinder comprehension. Simple and clear language is more effective in educating this population.

Choice C rationale:

Using common words with few syllables is important for ensuring that older clients can easily understand the educational materials. Complex language and lengthy words can make it difficult for them to grasp important information about their antihypertensive medications.

Choice D rationale:

Using pictures to help illustrate complex ideas is essential when educating older clients. Visual aids can enhance comprehension and retention of information, especially for individuals who may have cognitive impairments or difficulty with written text.

Choice E rationale:

Printing materials using a 12-point type font is important for ensuring that the text is easy to read for older clients. Smaller fonts can be challenging for individuals with visual impairments, and readability is crucial for effective education.

A. Carry on with surgical preparation of the client without a signed informed consent. B. Ask the man's friend to sign the informed consent since the client is unresponsive. C. Notify the unit manager that an emergency court order is needed to allow surgery. D. Continue to provide life support until a thorough search for a guardian is completed.

Correct Answer is A

Explanation

The correct answer is choicea. Carry on with surgical preparation of the client without a signed informed consent.

Choice A rationale:

In emergency situations where immediate surgery is required to save a patient’s life and no family members are available, the doctrine of presumed consent applies.This means that healthcare providers can proceed with necessary treatment without a signed informed consent to prevent serious harm or death.

Choice B rationale:

Asking the man’s friend to sign the informed consent is not appropriate because friends are not legally authorized to provide consent for medical procedures unless they have legal documentation proving their authority.

Choice C rationale:

Notifying the unit manager for an emergency court order would delay the necessary surgery, which could be detrimental to the patient’s health. In emergencies, immediate action is required, and waiting for a court order is not feasible.

Choice D rationale:

Continuing to provide life support while searching for a guardian would also delay the necessary surgery. In life-threatening situations, immediate surgical intervention is prioritized over finding a legal guardian.

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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

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.).

Correct Answer is ["A","D"]

Explanation

An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Correct Answer is A

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

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Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

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.).