A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

Measure body temperature.

Palpate for pedal edema.

Observe breathing patterns.

Assess blood pressure.

Answer and Explanation

The Correct Answer is C,A,D,B

Step 1: Observe breathing patterns. Respiratory depression is a critical symptom of myxedema coma that requires immediate attention.

Step 2: Measure body temperature. Hypothermia is a common symptom of myxedema coma and can provide important information about the severity of the patient’s condition.

Step 3: Assess blood pressure. Hypotension can occur in myxedema coma and can indicate the severity of the patient’s condition.

Step 4: Palpate for pedal edema. While this can be a symptom of hypothyroidism, it is not typically a primary concern in a patient showing signs of myxedema coma.

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Correct Answer is B

Explanation

Choice A rationale

Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.

Choice B rationale

Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.

Choice C rationale

Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.

Choice D rationale

Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.

A. Administer 0.2 mg methylergonovine IM B. Notify primary healthcare provider C. Insert straight catheter D. Massage fundus until firm E. Count saturated pads per hour F. Administer 2 units of packed red blood cells (PRBC) G. Increase the IV fluid to maximum rate H. Weigh all bloody materials .

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale

Methylergonovine is used after childbirth to help control bleeding and improve muscle tone in the uterus. Administering 0.2 mg of methylergonovine IM can help to control postpartum hemorrhage in this patient.

Choice B rationale

Notifying the primary healthcare provider is crucial in this situation. The healthcare provider needs to be aware of the patient’s condition and the interventions being initiated.

Choice C rationale

Inserting a straight catheter can help to manage urinary retention, which could be a potential issue given the patient’s prolonged labor and use of epidural anesthesia.

Choice D rationale

Massaging the fundus until it is firm can help to stimulate uterine contractions, which can control bleeding and prevent postpartum hemorrhage.

Choice E rationale

Counting saturated pads per hour can help to monitor the amount of bleeding and assess the effectiveness of the interventions.

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A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

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Correct Answer is B

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A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)